Functional outcomes by reconstruction technique following laparoscopic proximal gastrectomy for gastric cancer: double tract versus jejunal interposition

Complete laparoscopic and Da Vinci robot esophagogastric anastomosis double muscle flap plasty for radical resection of proximal gastric cancer

Objective

To investigate the application value of complete laparoscopy and Da Vinci robot esophagogastric anastomosis double muscle flap plasty in radical resection of proximal gastric cancer.

Method

A retrospective descriptive study was used. The clinicopathological data of 35 patients undergoing radical operation for proximal gastric cancer admitted to Liaoning Cancer Hospital from January 2020 to December 2023 were collected. Variables evaluated: 1. Transoperative,2. Postoperative, 3. Follow-up. In relation to follow-up, esophageal disease status reflux, anastomosis, nutritional status score, serum hemoglobin, tumor recurrence, and metastasis were investigated. The trans and postoperative variables were obtained from the clinical records and the patients were followed up in outpatient department and by telephone.

Result

Among the 35 patients, 17 underwent robotic surgery and 18 underwent laparoscopic surgery. There were 29 males and 6 females. 1) Transoperative: Robotic surgery: The operation time was (305.59 ± 22.07) min, the esophagogastric anastomosis double muscle flap plasty time was (149.76 ± 14.91) min, the average number of lymph nodes cleared was 30, and the average intraoperative blood loss was 30 ml. Laparoscopic surgery: The mean operation time was 305.17 ± 26.92min, the operation time of esophagogastric anastomosis double muscle flap was (194.06 ± 22.52) min, the average number of lymph nodes cleared was 24, and the average intraoperative blood loss was 52.5 ml. 2) Postoperative: Robotic surgery: the average time for patients to have their first postoperative anal emission was 3 days, the average time to first postoperative feeding was 4 days, and the average length of hospitalization after surgery was 8 days. Laparoscopic surgery: the average time for patients to have their first postoperative anal emission was 5 days, the average time to first postoperative feeding was 6 days, the average length of hospitalization after surgery was 10 days. 3) Follow-up: The follow-up time ranged from 1 to 42 months, with a median follow-up time of 24 months.

Conclusion

Complete Da Vinci robot and laparoscopic esophagogastric anastomosis double muscle flap plasty for radical resection of proximal gastric cancer can minimize surgical incision, reduce abdominal exposure, accelerate postoperative recovery of patients, and effectively prevent reflux esophagitis and maintain good hemoglobin concentration and nutritional status. The advantages of robotic surgery is less intraoperative bleeding and faster post-surgical recovery, but it is relatively more expensive.

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.

Uncut interposed jejunum pouch versus esophago-gastrostomy and double anastomoses of jejunum to the esophagus and residual stomach: An innovative method of digestive tract reconstruction following proximal gastrectomy

AIM

An innovative method of digestive tract reconstruction following proximal gastrectomy, the uncut interposed jejunum pouch, esophagus and residual stomach double anastomosis(Uncut-D), was established in recent years. In order to fully clarify the superiority of the procedure, this study has conducted a systematic analysis and thorough discussion.

METHODS

118 patients with adenocarcinoma of the esophagogastric junction who underwent proximal gastrectomy were enrolled in this study. According to the methods of digestive tract reconstruction, these patients were divided into three groups: Uncut-D(n = 43), esophagogastrostomy (EG, n = 36), jejunal interposition (JI, n = 39).The preoperative indicators, surgical complications and related indicators of postoperative quality of life were analyzed.

RESULTS

There were no significant differences in preoperative data among all groups (P > 0.05); The digestive tract reconstruction time in Uncut-D group was more than that in EG group, and less than that in JI group (P < 0.05). The incidence of esophageal anastomotic stenosis in Uncut-D group was significantly lower than that in EG group (P < 0.05); In Uncut-D group, the incidence of reflux esophagitis, postoperative nutrition index(PNI), weight recovery and Visick classification were significantly better than those in EG group (P < 0.05), furthermore, the incidence of delayed gastric emptying,PNI and weight recovery were better than those in JI group (P < 0.05).

CONCLUSIONS

The Uncut-D procedure gave full play to jejunal continuity and the advantages of pouch, and played a valuable role in gastric and cardiac replacement, which significantly reduced long-term complications, improved postoperative nutritional status of patients and long-term quality of life.

Prognostic nutritional index is a prognostic factor for patients with gastric cancer and esophagogastric junction cancer undergoing proximal gastrectomy with esophagogastrostomy by the double-flap technique: A secondary analysis of the rD-FLAP study

PURPOSE

Although proximal gastrectomy (PG) is commonly used in patients with upper gastric cancer (GC) and esophagogastric junction (EGJ) cancer, long-term prognostic factors in these patients are poorly understood. The double-flap technique (DFT) is an esophagogastrostomy with anti-reflux mechanism after PG; we previously conducted a multicenter retrospective study (rD-FLAP) to evaluate the short-term outcomes of DFT reconstruction. Here, we evaluated the long-term prognostic factors in patients with upper GC and EGJ cancer.

METHODS

The study was conducted as a secondary analysis of the rD-FLAP Study, which enrolled patients who underwent PG with DFT reconstruction, irrespective of disease type, between January 1996 and December 2015.

RESULTS

A total of 509 GC and EGJ cancer patients were enrolled. Univariate and multivariate analyses of overall survival demonstrated that a preoperative prognostic nutritional index (PNI) < 45 (p < 0.001, hazard ratio [HR]: 3.59, 95% confidential interval [CI]: 1.93-6.67) was an independent poor prognostic factor alongside pathological T factor ([pT] ≥2) (p = 0.010, HR: 2.29, 95% CI: 1.22-4.30) and pathological N factor ([pN] ≥1) (p = 0.001, HR: 3.27, 95% CI: 1.66-6.46). In patients with preoperative PNI ≥45, PNI change (<90%) at 1-year follow-up (p = 0.019, HR: 2.54, 95%CI: 1.16-5.54) was an independent poor prognostic factor, for which operation time (≥300 min) and blood loss (≥200 mL) were independent risk factors. No independent prognostic factors were identified in patients with preoperative PNI <45.

CONCLUSIONS

PNI is a prognostic factor in upper GC and EGJ cancer patients. Preoperative nutritional enhancement and postoperative nutritional maintenance are important for prognostic improvement in these patients.

Digestive tract reconstruction after laparoscopic proximal gastrectomy for Gastric cancer: A systematic review

The incidence of gastroesophageal junction adenocarcinoma has gradually increased. Proximal gastrectomy or total gastrectomy is recommended for early gastric cancer of the upper third of the stomach. Because total gastrectomy is often accompanied by body mass loss and nutrient absorption disorders, such as severe hypoproteinemia and anemia, Proximal gastrectomy is more frequently recommended by researchers for early upper gastric cancer (T1N0M0) and Siewert II gastroesophageal junction cancer less than 4 cm in length. Although some functions of the stomach are retained after proximal gastrectomy, the anatomical structure of the gastroesophageal junction can be destroyed, and the anti-reflux effect of the cardia is lost. In recent years, as various reconstruction methods for anti-reflux function have been developed, some functions of the stomach are retained, and serious reflux esophagitis is avoided after proximal gastrectomy. In this article, we summarized the indications, advantages, and disadvantages of various classic reconstruction methods and latest improved reconstruction method including esophageal and residual stomach anastomosis, tubular gastroesophageal anastomosis, muscle flap anastomosis, jejunal interposition, and double-tract reconstruction.

Incidence of Metachronous Remnant Gastric Cancer after Proximal Gastrectomy with the Double-flap Technique (rD-FLAP-rGC Study): A Multicenter, Retrospective Study

BACKGROUND

Although proximal gastrectomy (PG) with the double-flap technique (DFT) is a function-preserving surgery that prevents esophagogastric reflux, there is a risk of developing metachronous remnant gastric cancer (MRGC). Moreover, details of MRGC and appropriate postoperative follow-up after PG with DFT are unclear.

METHODS

We reviewed the medical records of 471 patients who underwent PG with DFT for cancer in a preceding, multicenter, retrospective study (rD-FLAP Study). We investigated the incidence of MRGC, frequency of follow-up endoscopy, and eradication of Helicobacter pylori (H. pylori) infection.

RESULTS

MRGC was diagnosed in 42 (8.9%) of the 471 patients, and 56 lesions of MRGC were observed. The cumulative 5- and 10-year incidence rates were 5.7 and 11.4%, respectively. There was no clinicopathological difference at the time of primary PG between patients with and without MRGC. Curative resection for MRGC was performed for 49 (88%) lesions. All patients with a 1-year, follow-up, endoscopy interval were diagnosed with early-stage MRGC, and none of them died due to MRGC. Overall and disease-specific survival rates did not significantly differ between patients with and without MRGC. The incidence rate of MRGC in the eradicated group after PG was 10.8% and that in the uneradicated group was 19.6%, which was significantly higher than that in patients without H. pylori infection at primary PG (7.6%) (p = 0.049).

CONCLUSIONS

The incidence rate of MRGC after PG with DFT was 8.9%. Early detection of MRGC with annual endoscopy provides survival benefits. Eradicating H. pylori infection can reduce the incidence of MRGC.

Effect of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction vs Total Gastrectomy on Hemoglobin Level and Vitamin B12 Supplementation in Upper-Third Early Gastric Cancer: A Randomized Clinical Trial

IMPORTANCE

Patients undergoing proximal gastrectomy (PG) with double-tract reconstruction (DTR) have been reported to have an incidence of reflux esophagitis that is as low as that observed after total gastrectomy (TG). It is unclear whether PG has an advantage over TG for the treatment of patients with upper early gastric cancer (GC).

OBJECTIVE

To evaluate the effect of laparoscopic PG with DTR (LPG-DTR) vs laparoscopic TG (LTG) on levels of hemoglobin and vitamin B12 supplementation required among patients with clinically early GC in the upper third of the stomach (upper-third early GC).

DESIGN, SETTING, AND PARTICIPANTS

This multicenter open-label superiority randomized clinical trial was conducted at 10 institutions in Korea. A total of 138 patients with upper-third cT1N0M0 GC were enrolled between October 27, 2016, and September 9, 2018. Follow-up ended on December 3, 2020.

INTERVENTIONS

Patients were randomized to undergo either LPG-DTR or LTG.

MAIN OUTCOMES AND MEASURES

The primary co-end points were change in hemoglobin level and cumulative amount of vitamin B12 supplementation at 2 years after LPG-DTR or LTG. The secondary end points included morbidity, postoperative reflux esophagitis, quality of life, overall survival, and disease-free survival. Quality of life outcomes were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) 30-item core questionnaire (C30) and the EORTC QLQ stomach cancer-specific questionnaire at 3 months, 12 months, and 24 months.

RESULTS

Among 138 patients (mean [SD] age, 60.0 [10.9] years; 87 men [63.0%]; all of Asian race and Korean ethnicity), 68 (mean [SD] age, 56.7 [10.4] years; 39 men [57.4%]) were randomized to receive LPG-DTR and 69 (mean [SD] age, 61.3 [11.3] years; 48 men [69.6%]) were randomized to receive LTG. The mean (SD) changes in hemoglobin levels from baseline to month 24 were -5.6% (7.4%) in the LPG-DTR group and -6.9% (8.3%) in the LTG group, for an estimated difference of -1.3% (95% CI, -4.0% to 1.4%; P = .35). The mean (SD) cumulative amount of vitamin B12 supplementation was 0.4 (1.3) mg in the LPG-DTR group and 2.5 (3.0) mg in the LTG group, for an estimated difference of 2.1 mg (95% CI, 1.3-2.9 mg; P < .001). The late complication rates in the LPG-DTR and LTG groups were 17.6% and 10.1%, respectively (P = .31). The incidence of reflux esophagitis was not different between the LPG-DTR and LTG groups (2.9% vs 2.9%; P = .99). Compared with the LTG group, the LPG-DTR group had better physical functioning scores (85.2 [15.6] vs 79.9 [19.3]; P = .03) and social functioning scores (89.5 [17.9] vs 82.4 [19.4]; P = .03) on the EORTC QLQ-C30. Two-year overall survival (98.5% vs 100%; P = .33) and disease-free survival (98.5% vs 97.1%; P = .54) did not significantly differ between the LPG-DTR vs LTG groups.

CONCLUSIONS AND RELEVANCE

In this study, patients with upper-third early GC who received LPG-DTR required less vitamin B12 supplementation than those who received LTG, with no increase in complication rates and no difference in overall and disease-free survival rates. There was no difference in change in hemoglobin level between groups. In addition, the LPG-DTR group had better physical and social functioning than the LTG group. These findings suggest that LPG-DTR may be as safe as LTG and may be a function-preserving procedure for the treatment of patients with upper-third early GC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02892643.

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.

Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival

PURPOSE

The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic function-preserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown.

MATERIALS AND METHODS

We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups.

RESULTS

A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into "LTG for LPG" (LTG-P) and "LTG for LSTG" (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG.

CONCLUSIONS

LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival. Therefore, LFPG for upper early gastric cancer should be considered in older patients.

Is single tract jejunal interposition better than double tract reconstruction after proximal gastrectomy?

Double tract reconstruction (DTR) is the main digestive tract reconstruction method after proximal gastrectomy (PG). Single tract jejunal interposition (STJI) derived from the double tract reconstruction is also increasingly used in clinical practice. However, there is still a great controversy as to which of the two reconstruction methods can achieve better results. In this study, we systematically reviewed studies on DTR and STJI after PG and performed a meta-analysis. We searched PubMed, Embase, and Cochrane Library databases for clinical studies comparing DTR and STJI after PG to December 2021 without language restriction. Review Manager (version5.4) software was used to perform meta-analysis on operative outcomes, postoperative complications and nutritional outcomes. The protocol for this meta-analysis was registered with PROSPERO (CRD42022301455). Five randomized controlled trials involving 453 patients were included in the meta-analysis. There were no significant differences between DTR and STJI in terms of intraoperative blood loss, postoperative hospital stay, incidence of reflux esophagitis, anastomotic complications and total complications. The operation time of STJI group was longer than that of DTR group [WMD - 0.79; 95% CI (- 1.55, - 0.03)] [heterogeneity: χ² = 4.94, df = 3 (P = 0.18); I² = 39%, test for overall effect: Z = 2.04 (P = 0.04)]. The body weight of STJI group was significantly higher than that of DTR group at 6 months after surgery [WMD 3.90; 95% CI (0.56, 7.23)] [heterogeneity: τ² = 7.67, χ² = 19.76, df = 2 (P < 0.0001); I² = 90%, test for overall effect: Z = 2.29 (P = 0.02)]. To the best of our knowledge, this is the first systematic review and meta-analysis to compare the outcomes of DTR and STJI after PG. There were no significant differences in operative outcomes and postoperative complications between DTR and STJI after PG. Although STJI prolonged the operation time compared to DTR, postoperative nutritional outcomes of patients in the STJI group was significantly better than that in the DTR group. Therefore, compared to DTR, STJI may be more suitable for the vast majority of patients undergoing PG due to its better postoperative nutritional status.

Indications and technical aspects of proximal gastrectomy

According to the World Health Organization, gastric cancer is the fifth most common type of tumor, and is the third most common cause of tumor-associated death. Although gastric cancer incidence rates have decreased in the past few decades, the prevalence of proximal gastric cancer has been steadily rising in developed countries. Techniques regarding the improvement of treatment options must thus be developed. This can be achieved through incorporating both a wider use of endoscopic surgery (endoscopic mucosal resection-EMR, endoscopic submucosal dissection-ESD) and a review of applied surgical interventions. Even though there is no single international consensus available, the Japanese Gastric Cancer Association (JGCA) recommends proximal gastrectomy with D1+ lymphadenectomy in early gastric tumors. Despite recommendations from Asian guidelines and the short term outcomes of the KLASS 05 trial, surgical treatments in Western countries still rely on total gastrectomy. This is mostly due to technical and oncological challenges regarding surgical interventions in a proximal gastrectomy. However, the residual stomach after a proximal gastrectomy has been shown to diminish the incidence of dumping syndrome and anemia, and even improve postoperative quality of life (QoL). Therefore, it is necessary to define the place of proximal gastrectomy in the treatment of gastric cancers.

Quality of life comparison between esophagogastrostomy and double tract reconstruction for proximal gastrectomy assessed by Postgastrectomy Syndrome Assessment Scale ( PGSAS )‐45

Aim

The current study compared the postoperative quality of life (QOL) between the esophagogastrostomy method (PGEG) and double tract method (PGDT) after proximal gastrectomy using the Postgastretomy Syndrome Assessment Scale (PGSAS)-45.

Methods

Among the 2364 patients who received the PGSAS-45 questionnaire, 300 PGEG and 172 PGDT cases responded. The main outcomes measures (MOMs) consisted of seven subscales (SS) covering symptoms, meals (amount and quality), ability to work, dissatisfaction with daily life, physical and mental component summary of the 8-Item Short Form Health Survey (SF-8), and change in body weight, and were compared between PGEG and PGDT.

Results

Overall, PGDT promoted significantly better constipation SS scores (p < 0.05), whereas PGEG tended to promote better body weight (BW) loss% (p < 0.10). A stratified analysis based on the remnant stomach size revealed that among those with a remnant stomach size of 1/2, PGDT had significantly better constipation and dumping SS scores (p < 0.05) and tended to have better working conditions (p < 0.10) compared to PGEG. Even among those with the remnant stomach size of 2/3, PGDT had significantly better diarrhea SS scores, lesser dissatisfaction with symptoms, and better dissatisfaction with daily life SS scores (p < 0.05) and tended to have better constipation SS scores and lesser dissatisfaction with work (p < 0.10) compared to PGEG.

Conclusions

After comparing the QOLs of PGEG and PGDT, the stratified analysis according to remnant stomach sizes of 1/2 and 2/3 revealed that PGDT was relatively superior to PGEG for several MOMs.

Study protocol for comparing the efficacy of left-open single-flap technique versus double-flap technique after proximal gastrectomy: A multicenter randomized controlled trial

BACKGROUND

Proximal gastrectomy has gradually gained more attention due to its superiority in retaining the function of part of the stomach. The inevitable loss of the antireflux barrier and postoperative complications resulting from proximal gastrectomy can severely affect the quality of life. Continuous improvements in digestive tract reconstruction after proximal gastrectomy have yielded the development of a variety of methods with antireflux functions. Recently, our center attempted the left-open single-flap technique and initiated a multicenter, prospective, randomized controlled trial for patients undergoing proximal gastrectomy to reduce the difficulty of surgical anastomosis and the incidence of perioperative complications compared with the double-flap technique. These findings will provide more evidence-based medical research for the development of clinical guidelines.

METHODS/DESIGN

This study is a prospective, multicenter, randomized controlled clinical trial. We plan to recruit 250 patients who are eligible for proximal gastrectomy. After informed consent is obtained, patients will be randomly assigned to the trial group (left-open single-flap technique) and the control group (double-flap technique) in a 1:1 allocation ratio.

DISCUSSION

Increasingly, clinical studies have focused on the improvement of reconstruction modalities after proximal gastrectomy. Among these methods, the double-flap technique is a clinically effective method. The purpose of this study is to establish a prospective randomized controlled trial to compare the efficacy of the left-open single-flap technique versus the double-flap technique after proximal gastrectomy, aiming to provide more evidence-based medical studies for digestive tract reconstruction in proximal gastrectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier [NCT05418920].

Optimal Procedures for Double Tract Reconstruction After Proximal Gastrectomy Assessed by Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND

Although double tract reconstruction after proximal gastrectomy (PGDT) is commonly performed for proximal gastric or esophagogastric junction cancer, the impact of the procedure on postoperative quality of life (QOL) has not been clarified. We aimed to clarify the optimal PGDT procedure in terms of postoperative QOL.

METHODS

Postoperative QOL was analyzed in 172 patients who underwent PGDT for proximal gastric cancer and were enrolled in the PGSAS-NEXT study, a multicenter cross-sectional study in Japan (UMIN000032221), in relation to the remnant stomach size, length of interposed jejunum between the esophagojejunostomy (E-J) and jejunogastrostomy (J-G), and size of the J-G.

RESULTS

The remnant stomach size was approximately one-third in 13, half in 97, and two-thirds in 60 patients. Dissatisfaction scores for symptoms, diet, work, and daily life subscales were lower in patients with a larger stomach (p < 0.05). These patients also scored better in terms of weight loss (- 13.5%, - 14.0%, and - 11.2%, respectively) and amount of food ingested per meal (52%, 62%, and 66%). The length of the interposed jejunum was ≤ 10 cm in 62 and ≥ 11 cm in 97 patients. Weight loss (- 11.3% and - 13.8%) and dissatisfaction scores were better in the ≤ 10 cm group (p < 0.05). J-G size was ≤ 5 cm in 27 and ≥ 6 cm in 135 patients. The amount of food ingested (56%, 64%) and dissatisfaction scores were better in the > 6 cm group (p < 0.05).

CONCLUSIONS

Larger remnant stomach, shorter length of interposed jejunum, and longer J-G might contribute to better postoperative QOL after PGDT.

Comparative Study of Pyloromyotomy and H-M Pyloroplasty in Proximal Gastrectomy for Adenocarcinoma of Esophageal-Gastric Junction

INTRODUCTION

The incidence of adenocarcinoma of esophageal-gastric junction (AEJ) has been increasing in recent years. Esophagogastrostomy after proximal gastrectomy (PG-EG) is the most commonly used surgical method for this disease which causes a constant spasm of the pyloric sphincter by cutting the vagus nerve around the esophagus, so H-M pyloroplasty (Heineke-Mikulicz pyloroplasty) is often operated after PG-EG to prevent delayed gastric emptying. However, H-M pyloroplasty destroys anti-reflux structure of pylorus and leads to serious bile reflux. The present study was designed to compare pyloromyotomy and H-M pyloroplasty in proximal subtotal gastrectomy through clinical studies and animal experiments.

METHODS

We retrospectively evaluated the outcomes of 73 AEJ patients (39 underwent PG-EG with an H-M pyloroplasty and 34 underwent PG-EG with a pyloromyotomy) between January 2016 and August 2020, and perioperative variables were compared. In the animal experiment, 48 rats were randomly divided into four groups (n = 12): vagotomy group (V group), H-M pyloroplasty group (HM group), pyloromyotomy group (PM group), and control group (O group). Gastric emptying and bile reflux were evaluated in each group.

RESULTS

In the retrospective clinic study, pyloromyotomy and H-M pyloroplasty could all prevent delayed gastric emptying effectively, and the incidence of bile reflux found by electronic gastroscopy in the PM group was significantly lower than that in the HM group (HM, 14/39; PM, 4/34; P = 0.028). In the animal experiment, there was no significant between-group difference of gastric emptying rate (%) in the HM group and PM group (HM, 70.6 ± 16; PM, 72.3 ± 12; P = 0.68) while the gastric emptying rate (%) was significantly lower in the V group than in the HM, PM, and control group (P values were 0.037, 0.021, and 0.001 respectively). The gastric mucosa bile acid concentration was significantly higher in the HM group than other group (P values were all less than 0.001).

CONCLUSIONS

The pyloromyotomy could prevent delayed gastric emptying effectively after PG-EG for types II and III AEJ and reduce bile reflux compared to Heineke-Mikulicz pyloroplasty.

Clinical Outcomes of Laparoscopic Proximal Gastrectomy With Double-Flap Reconstruction for Tumors in the Upper Third of the Stomach

PURPOSE

Laparoscopic proximal gastrectomy (LPG) has been a standard surgery for early gastric cancer in the upper third of the stomach and large esophagogastric junction gastrointestinal stromal tumor. However, how to reconstruct the stomach after LPG is still debated. This study aimed to evaluate the results of LPG with double-flap reconstruction.

METHODS

A retrospective study was performed with 14 patients undergoing LPG with double-flap reconstruction for early gastric cancer or large tumors in the upper third of the stomach from 2018 to 2021. We evaluated postoperative complications, gastroesophageal reflux and the gastric remnant's function using endoscopy in accordance with the Los Angeles and Residue-Gastritis-Bile classifications, and patients' quality of life by the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire.

RESULTS

Median age was 54 years and 10 patients were male. There were 7 patients with gastrointestinal stromal tumor, 4 with leiomyoma and 3 with early-stage adenocarcinoma. No patient had major complications or required conversion to open surgery. During a median follow-up period of 24.6 months, 1 patient had late anastomotic stricture, 2 had metastasis, and 1 died. Endoscopic evaluation at 6 and 12 months showed good function of the gastric remnant in most patients. Patients' quality of life improved over time: mean GSRS score was 26.9±12.6, 20.3±7.2, and 18.8±4.2 at 6, 12, and 24 months, respectively.

CONCLUSIONS

LPG with double-flap reconstruction is feasible and safe for early gastric cancer or large tumors in the upper third of the stomach. The long-term functional outcomes and patients' quality of life were acceptable.

Protocol for Comparing the Efficacy of Three Reconstruction Methods of the Digestive Tract (Kamikawa Versus Double-Tract Reconstruction Versus Tube-Like Stomach) After Proximal Gastrectomy

Background

Appropriate gastrointestinal reconstruction after proximal gastrectomy can effectively reduce the incidence of postoperative complications in patients with proximal early gastric cancer. However, there is still great controversy about the choice of digestive tract reconstruction after proximal gastrectomy, and there is no clinical consensus on the choice of digestive tract reconstruction after proximal gastrectomy. Currently, there is a lack of large-sample, prospective, randomized controlled studies to compare the efficacy of Kamikawa, double-tract reconstruction, and tube-like stomach reconstruction after proximal gastrectomy.

Methods/design

This study will investigate the efficacy of three reconstruction methods after proximal gastrectomy in a prospective, multicenter, randomized controlled trial, which will enroll 180 patients with proximal early gastric cancer. Patients will be randomly divided into three groups: Group A (Kamikawa, n = 60), Group B (double-tract reconstruction, n = 60), and Group C (tube-like stomach, n = 60). The general information, past medical history, laboratory findings, imaging findings, and surgical procedures of the patients will be recorded and analyzed. The incidence of reflux esophagitis will be recorded as the primary endpoint. The incidence of anastomotic leakage, anastomotic stenosis, operative time and intraoperative blood loss will be recorded as secondary endpoints.

Discussion

This study will establish a large-sample, prospective, randomized controlled trial to compare the efficacy of Kamikawa, double-tract reconstruction, and tube-like stomach reconstruction after proximal gastrectomy.

Trial registration

This study was approved by the Chinese Clinical Trial Registry and registered on April 30, 2021. The registration number is ChiCTR2100045975.

“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.

Double tract reconstruction versus double flap technique: short-term clinical outcomes after laparoscopic proximal gastrectomy for early gastric cancer

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) is increasingly preferred for operative management of early gastric cancer, although there is no consensus on a standard reconstruction method after resection. Two popular methods used after LPG are double tract reconstruction (DTR) and double flap technique (DFT). This study assessed comprehensive clinical outcomes including quality of life (QoL) and body composition change 1 year after DFT and DTR.

METHODS

We retrospectively reviewed prospectively collected data from 51 to 18 patients who underwent DTR and DFT, respectively, between September 2014 and December 2018. Short-term surgical outcomes, presence of reflux esophagitis, nutritional supplementation, medications, nutritional status (laboratory results and body composition analysis), and QoL measured preoperatively and at 1 year postoperatively were compared between both groups.

RESULTS

Both groups did not differ significantly in clinicopathological characteristics. The DFT as compared to the DTR group required significantly longer time for anastomosis (79.4 vs. 60.9 min, p < 0.001) and use of fewer staplers (3.39 vs. 6.86, p < 0.001). While the presence of endoscopic reflux esophagitis and iron/vitamin B₁₂ replacement were comparable, the DTR group showed a higher tendency of taking anti-reflux medications for reflux symptoms (DTR: 13.7% vs. DFT: 0.0%, p = 0.177). The DTR group lost significantly more weight (p = 0.038) and body fat (p = 0.009). QoL analysis showed significant deterioration in diarrhea, eating restriction, and taste problems in both groups (DTR group: p = 0.008, p < 0.001, p = 0.010, respectively, and DFT group: p = 0.017, p = 0.024, p = 0.034, respectively). However, only the DTR group showed significant deterioration in physical function (p = 0.009), role function (p = 0.033), nausea/vomiting (p = 0.041), appetite loss (p = 0.019), dysphagia (p = 0.001), pain (p = 0.025), and body image (p = 0.004).

CONCLUSIONS

Despite requiring a longer anastomosis time, performing DFT after LPG was shown to be an ideal reconstruction method in terms of better 1-year QoL and nutritional outcome. Further larger studies over longer postoperative periods are necessary to confirm our findings.

Time interval after various types of gastrectomy until metachronous multiple gastric cancer: Analysis of data from a nationwide Japanese survey

The factors influencing the time interval from the initial surgery for gastric cancer to the detection of metachronous multiple gastric cancer (MMGC) remain to be elucidated. The present study was performed to evaluate the association between the type of initial gastrectomy or reconstruction procedure and the time interval from initial gastrectomy to the detection of MMGC. A questionnaire survey on remnant stomach cancer was performed by the Japanese Society for Gastro-Surgical Pathophysiology in 2018. Participating facilities were requested to indicate the number of patients who underwent surgery for MMGC between 2003 and 2017, in association with the time interval from the initial gastrectomy until treatment for MMGC by type of initial gastrectomy or reconstruction procedure. Analyses were performed using data from 45 facilities. Gastrectomy for MMGC was performed on 1,234 patients during this period. Pylorus-preserving gastrectomy (PPG) accounted for only 3.6% (20/557) of the patients who underwent surgery for MMGC ≥10 years from initial gastrectomy, while PPG accounted for 10.1% (40/396) of patients who underwent surgery for MMGC within 5 years after initial gastrectomy. Billroth-II and Roux-en Y reconstruction accounted for 22.3% (103/462) and 1.3% (6/462), respectively, of patients who underwent surgery for MMGC ≥10 years from initial distal gastrectomy (DG), while such patients accounted for 8.0% (23/286) and 21.7% (65/286), respectively, of patients who underwent surgery for MMGC within 5 years after initial DG. Similarly, the proportion of each reconstruction procedure differed according to the time interval from initial proximal gastrectomy to treatment for MMGC. The types of gastrectomy or reconstruction procedure for initial gastrectomy differed significantly according to the time interval between the initial gastrectomy and treatment for MMGC, and the fact that PPG and R-Y reconstruction in DG is a relatively new method were assumed to be a major cause of these differences.

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.

Functional benefits of the double flap technique after proximal gastrectomy for gastric cancer

BACKGROUND

Proximal gastrectomy is a widely performed procedure that has become more common with an increasing number of proximal gastric cancer cases. Several types of reconstructive procedures after proximal gastrectomy have been developed, and it remains controversial which procedure is the most advantageous with regard to the preservation of postoperative gastric stump function and nutritional status. In the present study, we retrospectively analyzed reconstructive procedures in a consecutive case series for proximal gastrectomy, primarily focusing on postoperative body weight maintenance, nutritional status, and gastric remnant functional preservation.

METHODS

We enrolled 69 patients who had undergone proximal gastrectomy for gastric cancer in our institute between 2005 and 2020. Short-term complications, preservation of gastric remnant functions, nutritional status, and post-operative weight changes were compared.

RESULTS

After proximal gastrectomy, the numbers of patients who underwent direct esophago-gastrostomy, jejunal interposition, double tract reconstruction, and the double flap technique were 9, 10, 14, and 36, respectively. The patients in whom the double flap technique was performed suffered no reflux esophagitis after surgery. Prevalence of gastric residual at 12 months after surgery was lowest in the double flap technique group. Moreover, the double flap technique group had a better tendency regarding post-operative changes of serum albumin ratios. Furthermore, the post-operative body weight change ratio of the double flap technique group was smallest among all groups and was significantly better than that of the double tract group.

CONCLUSIONS

The double flap technique after proximal gastrectomy was considered the most effective technique for reconstruction which leads to better bodyweight maintenance, and results in less reflux esophagitis.

Various Kinds of Functional Digestive Tract Reconstruction Methods After Proximal Gastrectomy

The incidence of proximal gastric cancer has shown a rising trend in recent years. Surgery is still the main way to cure proximal gastric cancer. Total gastrectomy with D2 lymph node dissection was considered to be the standard procedure for proximal gastric cancer in the past several decades. However, in recent years, many studies have confirmed that proximal gastrectomy can preserve part of the stomach function and can result in a better quality of life of the patient than total gastrectomy. Therefore, proximal gastrectomy is increasingly used in patients with proximal gastric cancer. Unfortunately, there are some concerns after proximal gastrectomy with traditional esophagogastrostomy. For example, the incidence of reflux esophagitis in patients who underwent proximal gastrectomy with traditional esophagogastrostomy is significantly higher than those patients who underwent total gastrectomy. To solve those problems, various functional digestive tract reconstruction methods after proximal gastrectomy have been proposed gradually. In order to provide some help for clinical treatment, in this article, we reviewed relevant literature and new clinical developments to compare various kinds of functional digestive tract reconstruction methods after proximal gastrectomy mainly from perioperative outcomes, postoperative quality of life and survival outcomes aspects. After comparison and discussion, we drew the conclusion that various functional reconstruction methods have their own advantages and disadvantages; large scale high-level clinical studies are needed to choose an ideal reconstruction method in the future. Besides, in clinical practice, surgeons should consider the condition of the patient for individualized selection of the most appropriate reconstruction method.

A novel method of esophagogastrostomy by overlap anastomosis with placement of the remnant stomach into the lower mediastinum after laparoscopic proximal gastrectomy

INTRODUCTION

Control of postoperative gastroesophageal reflux (GER) is a critical consideration for patients who undergo proximal gastrectomy. This report describes a new and simple reconstruction method by esophagogastrostomy with placement of the remnant stomach into the lower mediastinum (EG-PRIME). This approach not only suppresses postoperative GER, but it can also be easily performed by total laparoscopy. Detailed herein are the methods for EG-PRIME and the results for three patients with cancer of the upper gastric body.

MATERIALS AND SURGICAL TECHNIQUE

At the start of the EG-PRIME surgical procedure, a pseudo-fornix and lozenge-shaped gastric conduit were made by cutting the stomach diagonally. Next, the pseudo-fornix was inserted into the esophageal hiatus to form a new angle of His. Then overlap anastomosis was performed and the entry site was closed longitudinally. The outcomes assessed were operative time, intraoperative blood loss, postoperative complications and GER according to 24-hour pH monitoring.

DISCUSSION

The operative times were 339, 288 and 236 minutes; in two patients, intraoperative blood loss was 260 and 343 mL, and in the third, blood loss was minimal. No postoperative complications were observed in any of the three patients. The degree of the GER resulting in fraction time pH<4 was 9.0%, 0.3%, and 2.9%, respectively. No esophagitis by upper gastrointestinal endoscopy was observed in any patient. This EG-PRIME method was technically feasible for reconstruction after proximal gastrectomy by total laparoscopy. This approach may be as simple and useful as esophagogastrostomy for preventing postoperative GER, but more experience with this method is required.

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.

Esophagogastrostomy With Fundoplication Versus Double-tract Reconstruction After Laparoscopic Proximal Gastrectomy for Gastric Cancer

PURPOSE

We investigated that double-tract reconstruction (DTR) may be more beneficial than esophagogastrostomy (EG) with fundoplication in terms of nutritional outcomes, focusing on loss of body weight.

MATERIALS AND METHODS

This study included 56 consecutive patients with early gastric cancer in the upper third of the stomach who received laparoscopic proximal gastrectomy, 39 underwent EG. In the 17 patients requiring resection of the abdominal esophagus or where the size of the remnant stomach was 50% or less, we performed DTR.

RESULTS

There was no significant difference in the rate of body weight change at 6 or 12 months, or in biochemical markers (hemoglobin, total protein, and albumin) at 12 months. However, 8 patients in the EG group had extreme body weight loss (≥20%) within 12 months. Conversely, in the DTR group, no patients had any extreme body weight loss.

CONCLUSION

DTR is useful after laparoscopic proximal gastrectomy, especially in terms of preventing extreme body weight loss.

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.

Laparoscopic proximal gastrectomy with double-tract reconstruction for upper third gastric cancer

Background

Proximal gastrectomy with double-tract reconstruction (DTR) has been used for upper third gastric cancer as a function-preserving procedure. However, the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with DTR remain uncertain. This study compared open proximal gastrectomy (OPG) with DTR and LPG with DTR for proximal gastric cancer.

Methods

Sixty-four patients who had undergone OPG with DTR and forty-six patients who had undergone LPG with DTR were enrolled in this case–control study. The clinical characteristics, surgical outcomes and postoperative nutrition index were analysed retrospectively.

Results

The operation time was significantly longer in the LGP group than in the OPG group (258.3 min vs 205.8 min; p = 0.00). However, the time to first flatus and postoperative hospital stay were shorter in the LPG group [4.0 days vs 3.5 days (p = 0.00) and 10.6 days vs 9.2 days (p = 0.001), respectively]. No significant difference was found between the two groups in the number of retrieved lymph nodes, complications or reflux oesophagitis. The nutrition status was assessed using the haemoglobin, albumin, prealbumin and weight levels from pre-operation to six months after surgery. No significant difference was found between the groups.

Conclusion

LPG with DTR can be safely performed for proximal gastric cancer patients by experienced surgeons.

Comparison of Postoperative Quality of Life among Three Different Reconstruction Methods After Proximal Gastrectomy: Insights From the PGSAS Study

BACKGROUND

Proximal gastrectomy (PG) has become an increasingly preferred procedure for early cancer in the upper third of the stomach, owing to reportedly superior quality of life (QOL) after PG when compared with total gastrectomy. However, various methods of reconstruction have currently been proposed. We compared the postoperative QOL among the three different reconstruction methods after PG using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire.

METHODS

Post Gastrectomy Syndrome Assessment Study (PGSAS), a nationwide multi-institutional survey, was conducted to evaluate QOL using the PGSAS-45 among various types of gastrectomy. Of the 2,368 eligible data from the PGSAS survey, data from 193 patients who underwent PG were retrieved and used in the current study. The PGSAS-45 consists of 45 items including 22 original gastrectomy specific items in addition to the SF-8 and GSRS. These were consolidated into 19 main outcome measures pertaining postgastrectomy symptoms, amount of food ingested, quality of ingestion, work, and level of satisfaction for daily work, and the three reconstruction methods (n = 193; 115 esophago-gastrostomy [PGEG], 34 jejunal interposition [PGJI], and 44 jejunal pouch interposition [PGJPI]) were compared using PGSAS-45.

RESULTS

Size of the remnant stomach was significantly larger in PGEG, and significantly smaller in PGJI and PGJPI (P < 0.05). There was no difference in other patient background factors among the groups. EGJPI tended to be superior to PGEG in several of the 19 main outcome with marginal significance (P = 0.047-0.076).

CONCLUSION

PGJPI appears to be the most favorable of the three reconstruction methods after PG especially when the size of remnant stomach is rather small.

TRIAL REGISTRATION NUMBER

UMIN-CTR #000002116 entitled as "A study to observe correlation between resection and reconstruction procedures employed for gastric neoplasms and development of postgastrectomy syndrome".

A novel method for π-shaped esophagojejunostomy and double-tract reconstruction (DTR) as an alternative in totally laparoscopic or robotic proximal gastrectomy for treating upper third proximal early gastric cancer

This study evaluated the impact of a new intracorporeal π-shaped esophagojejunostomy (EJS) and double-tract reconstruction (DTR) in totally laparoscopic and totally robotic proximal gastrectomy (TLPG or TRPG) for treating upper third early gastric cancer (U-EGC) in terms of intraoperative and short-term postoperative outcomes. Early proximal gastric cancer patients were identified based on a prospectively established database. From January 2017 to December 2018, these patients underwent intracorporeal π-shaped EJS and DTR after totally laparoscopic (n = 8) or robotic (n = 4) proximal gastrectomy (PG). We recorded and analyzed the baseline characteristics and surgical outcomes, including postoperative complications for these patients. No severe postoperative complications were observed following the operational procedures. Twelve patients (seven male and five female) diagnosed with cardia cancer (Siewert II and III) were enrolled, of which eight underwent the totally laparoscopic proximal gastrectomy (TLPG), and four underwent the totally robotic proximal gastrectomy (TRPG). The mean operative time, blood loss, day of the start of the diet, and postoperative hospital stay was 235.54 ± 20.79 min, 50.65 ± 35.44 mL, 3.85 ± 0.65 days, and 12.45 ± 3.24 days, respectively. All patients presented with a diagnosis of stage I gastric cancer. The mean number of lymph node dissections and the maximum tumor diameter was 13.91 ± 4.63 and 2.18 ± 0.73 cm, respectively. After the operational procedure, using the iodoethylene contrast reagent, we observed that a large proportion of iodoethylene contrast agents entered the jejunum directly, and a small proportion entered the jejunum through the duodenum. Surgeons followed up with ten patients for more than 12 months and the remaining two patients for more than 24 months. None of the patients showed any signs of anastomotic stenosis or reflux esophagitis or anemia symptoms. This study presents a novel method for π-shaped EJS and DTR as an alternative in TLPG or TRPG for treating proximal early gastric cancer, and it offers better short-term postoperative and intraoperative surgical outcomes.

Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report

Patient: Male, 73-year-old

Final Diagnosis: Achalasia

Symptoms: Dysphagia

Medication:—

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Short and long-term outcomes after proximal gastrectomy with double tract reconstruction for Siewert type III adenocarcinoma of the esophagogastric junction: a propensity score matching study from a 10-year experience in a high-volume hospital

BACKGROUND

Total gastrectomy and proximal gastrectomy (PG) are both surgical options for the treatment of Siewert type III adenocarcinoma of the esophagogastric junction (AEG). Currently there is no consensus on selecting which procedure to perform; in particular, there are few reports of long-term outcomes for patients with local advanced AEG. The aim of this study was to validate the usefulness of PG with double-tract reconstruction in Siewert type III AEG.

METHODS

The clinical data of patients with Siewert type III AEG underwent PG with double-tract reconstruction (PG-DT) or total gastrectomy with Roux-en-Y anastomosis (TG-RY) at our hospital between October 2010 and October 2018. According to the defined inclusion and exclusion criteria, 2,146 cases were enrolled in this study. A 1-to-1 propensity score matching (PSM) was performed to compare the short and long-term outcomes between the 2 groups.

RESULTS

The operation time was longer in the PG-DT group, and the proportion rates of complications and recovery time was similar in the 2 groups. The rates of maintaining bodyweight and free-fat mass index were significantly higher in patients who underwent PG-DT compared to those who underwent TG-RY. While complications, recovery time and survival are similar between two groups.

CONCLUSIONS

Regarding short-term outcomes, PG-DT seemed to be superior in terms of maintaining body weight and skeletal muscle compared to TG-RY, while both had similar complications. It was found that PG-DT enabled a potentially longer survival of pathological stage II and III Siewert type III AEG, although the finding was statistically insignificant. These results may help surgeons to determine the appropriate surgical approach and strategy for patients with early and locally advanced Siewert type III AEG.

Comparisons of Postoperative Complications and Nutritional Status After Proximal Laparoscopic Gastrectomy with Esophagogastrostomy and Double-Tract Reconstruction

Background

The purpose of this study was to compare postoperative complications and nutritional status between esophagogastrostomy and double-tract reconstruction in patients who underwent laparoscopic proximal gastrectomy, and assess the advantages of both surgical procedures.

Methods

Between 2010 and 2018, 47 cases underwent proximal gastrectomy with esophagogastrostomy (n = 23) or double-tract reconstruction (n = 24) at our institution for the treatment of clinical T1N0 adenocarcinoma located in the upper third of the stomach. Patient clinical characteristics, short-term outcomes, nutrition status, and skeletal muscle index were compared among the two groups.

Results

There was no significant difference between esophagogastrostomy and double-tract reconstruction in terms of operation time, blood loss, and length of postoperative hospital stay. Reflux symptoms and anastomotic stenosis were significantly higher in the esophagogastrostomy group compared with the double-tract reconstruction group (P < 0.001 and P = 0.004, respectively). There was no significant difference in anastomotic leakage, surgical site infection, and pancreatic fistula. For the nutritional status, the decrease rate of cholinesterase was significantly higher in the esophagogastrostomy group compared with the double-tract reconstruction group at 6 months (P = 0.008) There was no significant difference in the decrease rate of skeletal muscle mass index at 1 year after surgery.

Conclusion

Compared with esophagogastrostomy, double-tract reconstruction tends to have better short-term nutritional status and postoperative outcomes in terms of preventing the occurrence of gastroesophageal reflux and anastomosis stenosis. These findings suggest that double-tract reconstruction may be a useful method in laparoscopic proximal gastrectomy.

The Hepatic Left Lateral Segment Inverting Method Offering a Wider Operative Field of View During Laparoscopic Proximal Gastrectomy

BACKGROUND

In laparoscopic proximal gastrectomy, the hepatic left lateral segment often obstructs the operative field of view, especially around the esophageal hiatus. Therefore, a safe retraction method is needed. The present study aimed to determine the effectiveness of inverting the hepatic left lateral segment in laparoscopic proximal gastrectomy.

METHODS

This was a retrospective review of 81 consecutive patients who underwent laparoscopic proximal gastrectomy. Patients were divided into two groups, i.e., the Nathanson liver retractor group (n = 41) and hepatic left lateral segment inverting group (n = 40). The unedited video recordings of the procedures and the patients' medical records were reviewed and compared.

RESULTS

The hepatic left lateral segment inverting method provided a more satisfactory view of the operative fields and a wider working space around the esophageal hiatus than the Nathanson liver retractor. No intraoperative hepatic congestion and significantly improved postoperative liver enzyme elevations were observed with hepatic left lateral segment inverting method compared with the Nathanson liver retractor method.

CONCLUSIONS

In laparoscopic proximal gastrectomy, the hepatic left lateral segment inverting method appears to provide improvements in both the operative field of view and liver protection compared with the Nathanson liver retractor method.

Current status of laparoscopic proximal gastrectomy in proximal gastric cancer: Technical details and oncologic outcomes

The incidence of proximal gastric cancer has been increasing continuously. This status has prevailed despite the application of laparoscopic proximal gastrectomy as a surgical treatment for early proximal gastric cancer. The widespread adoption and standardization of this surgical procedure as the primary treatment for the abovementioned cancer has been hampered by the lack of consensus on the optimal reconstruction method after proximal gastrectomy. In addition, the oncological safety of proximal gastrectomy for advanced gastric disease remains unclear. We reviewed the English-language literature to clarify the current status of laparoscopic proximal gastrectomy in proximal gastric cancer. Japanese gastric cancer guidelines have suggested three types of reconstructions for proximal gastrectomy, namely, esophagogastrostomy, double-tract reconstruction, and jejunal interposition. Optimal reconstruction methods remain to be determined because of the lack of adequately performed and well-designed randomized controlled trials. The technical complexity and challenging implementation of reconstruction procedures have resulted in several complications with anastomoses. Multicenter randomized controlled trials are necessary to evaluate the various reconstruction methods and the oncological safety of laparoscopic proximal gastrectomy for advanced gastric disease.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis

BACKGROUND

Additional studies comparing several reconstruction methods after proximal gastrectomy have been published; of note, it is necessary to update systematic reviews and meta-analysis from the current evidence-based literature.

AIM

To expand the current knowledge on feasibility and safety, and also to analyze postoperative outcomes of several reconstructive techniques after proximal gastrectomy.

METHODS

PubMed, Google Scholar, and Medline databases were searched for original studies, and relevant literature published between the years 1966 and 2019 concerning various reconstructive techniques on proximal gastrectomy were selected. The postoperative outcomes and complications of the reconstructive techniques were assessed. Meta-analyses were performed using Rev-Man 5.0. A total of 29 studies investigating postoperative outcomes of double tract reconstruction, jejunal pouch interposition, jejunal interposition, esophagogastrostomy, and double flap reconstruction were finally selected in the quantitative analysis.

RESULT

Pooled incidences of reflux esophagitis for double tract reconstruction, jejunal pouch interposition, jejunal interposition esophagogastrostomy, and double flap reconstruction were 8.6%, 13.8%, 13.8%, 19.3%, and 8.9% respectively. Meta-analysis showed a decreased length of hospital in the JI group as compared to the JPI group (heterogeneity: Chi2 = 1.34, df = 1 (P = 0.25); I2 = 26%, test for overall effect: Z = 2.22 (P = 0.03). There was also a significant difference between JI and EG in length of hospital stay with heterogeneity: Chi2 = 1.40, df = 3 (P = 0.71); I2 = 0%, test for overall effect: Z = 5.04 (P < 0.00001). Operative time was less in the EG group as compared to the JI group (heterogeneity: Chi2 = 31.09, df = 5 (P < 0.00001); I2 = 84%, test for overall effect: Z = 32.35 (P < 0.00001).

CONCLUSION

Although current reconstructive techniques present excellent anti-reflux efficacy, the optimal reconstructive method remains to be determined. The double flap reconstruction proved to lower the rate of complication, but the DTR, JI, JPI, and EG groups showed higher incidence of complications in anastomotic leakage, anastomotic stricture, and residual food. In the meta-analysis result, the complications between the JI, JPI, and EG were comparable but the EG group showed to have better postoperative outcomes concerning the operative time, blood loss, and length of hospital stay.

Double-Tract Reconstruction Designed to Allow More Food Flow to the Remnant Stomach After Laparoscopic Proximal Gastrectomy

PURPOSE

Laparoscopic proximal gastrectomy (LPG) is a function-preserving surgery performed on patients with cancer of the upper third of the stomach. However, if much of the ingested food passes through the jejunum, LPG might function broadly like a total gastrectomy. We devised a jejunogastrostomy with double-tract reconstruction (DTR) to ensure that most food flows easily to the remnant stomach.

METHODS

A side-to-side jejunogastrostomy was created between the remnant stomach's posterior wall and the jejunum 10 cm below the esophagojejunostomy, and the common stab incision was also closed with a linear stapler. The jejunogastrostomy was created as a delta-shaped anastomosis by using only linear staplers. The 15 patients who underwent delta-shaped anastomosis from 2017 to 2018 were retrospectively reviewed to collect and analyze their surgical and postoperative outcomes, including nutritive conditions, in comparison to the reconstruction that was performed before then.

RESULTS

Operative times and postoperative complications were not significantly different compared to the previous reconstruction. We confirmed significant differences in operative bleeding and passage of food through the remnant stomach. The level of nutritional indicators at the end of postoperative year one did not tend to be lower, but total weight loss (TWL) and %TWL were significantly lower. As expected, there was a correlation between differences in jejunogastrostomy type and postoperative malnutrition.

CONCLUSIONS

This method devised for intracorporeal DTR provided patients with improved postoperative nutritional status by directing more food through the remnant stomach after LPG.

Comparison of three digestive tract reconstruction methods for the treatment of Siewert II and III adenocarcinoma of esophagogastric junction: a prospective, randomized controlled study

BACKGROUND

The incidence of adenocarcinoma of esophagogastric junction (AEG) has recently risen worldwide, including in Eastern Asia. The aim of the study was to explore the short-term and long-term clinical efficacy of piggyback jejunal interposition reconstruction single-tract reconstruction (PJIRSTR), piggyback jejunal interposition reconstruction double-tract reconstruction (PJIRDTR), and total gastrectomy esophageal jejunal Roux-en-Y anastomosis (TGRY) for the treatment of Siewert II and III AEG patients.

METHODS

A total of 300 Siewert II and III AEG patients admitted to Shanxi Tumor Hospital from June 2015 to December 2017 were prospectively selected. Patients were randomly divided into PJIRSTR group (n = 98), PJIRDTR group (n = 103), and TGRY group (n = 99) using the random number table method.

RESULTS

There were no statistically significant differences in total operation time, intraoperative blood loss, time of first anal exhaust, and postoperative hospital stay among the three groups (F = 2.526, 0.457, 0.234, 0.453; P > 0.05). The reconstruction time of PJIRSTR group and PJIRDTR group was longer than that of TGRY group (P < 0.01). There were no significant differences in cases of anastomotic leakage, anastomotic bleeding, abdominal infection, incision infection, ileus, and dumping syndrome in three groups (P > 0.05). The incidence of reflux esophagitis at 3, 6, 12, and 18 months after surgery in the PJIRSTR group and the PJIRDTR group were significantly lower than TGRY group in the same period (P < 0.05). Compared with PJIRDTR group and TGRY group, PJIRSTR group had a small fluctuation range of postoperative nutrition indexes and had basically recovered to the preoperative level at 18 months. Four patients of Visick grade IV presented in TGRY group 18 months postoperatively, which was significantly higher compared with the other two groups.

CONCLUSION

Compared with PJIRDTR and TGRY, PJIRSTR can significantly reduce the incidence of postoperative reflux esophagitis and improve the long-term nutritional status of patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IIR-16007733. Registered 07 November 2015 - Retrospectively registered, http://www.chictr.org.cn/searchproj.aspx.

Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-third gastric cancer

BACKGROUND

Double-flap technique (DFT) has received increased attention as an anastomotic procedure preventing reflux esophagitis after laparoscopic proximal gastrectomy (LPG) for upper-third gastric cancer. However, incidence of anastomotic stricture still remains high. This study was a retrospective review aimed to demonstrate details of surgical outcomes and to assess risk factors for anastomotic complications using pre-operative CT image after LPG with DFT (LPG-DFT).

METHODS

Patient background data, surgical outcomes, post-operative courses, and complications for patients who underwent LPG-DFT from January 2013 to June 2017 were collected. In addition to the details of short-term outcomes, risk factors for anastomotic stricture and gastroesophageal reflux were analyzed.

RESULTS

The study sample was 147 patients, including 139 patients with upper-third gastric cancer and 8 patients with submucosal tumor of the upper-third stomach. The overall morbidity rate was 12.2% (18/147), and 97.3% (143/147) of the patients achieved R0 resection. Twelve (8.3%) patients required endoscopic balloon dilatation for anastomotic stenosis, and six (4.2%) suffered regurgitation grade ≥ B in the Los Angeles classification. Multivariate analysis revealed that diameter of the esophagus < 18 mm on pre-operative CT image and the presence of short-term complications were found to be independent risk factors for post-operative anastomotic stenosis. No specific risk for gastroesophageal reflux was identified.

CONCLUSIONS

The incidence rate of anastomotic complications after LPG-DFT was far lower than that reported after conventional esophagogastrostomy. Alternative anastomotic method may be considered for patients with diameter of the esophagus < 18 mm on pre-operative CT image. Prevention of short-term complications may lessen post-operative stricture.

Laparoscopic esophagogastrostomy using a knifeless linear stapler after proximal gastrectomy

Proximal gastrectomy should improve the late postoperative function in patients with gastric cancer located in the upper third of the stomach or esophagogastric junction. However, a standard method of esophagogastrostomy has not been established for improving the postoperative function. To prevent reflux and stenosis following proximal gastrectomy, we introduced a novel esophagogastrostomy method using a knifeless linear stapler. The stapler was inserted into holes created in both the esophagus and remnant stomach and fired proximally. A 1.5-cm incision was made from the edge of the entry hole between the staples. The entry hole was then closed with continuous sutures, and fundoplication was performed by wrapping the remnant stomach. We performed this technique in 12 consecutive patients without observing any anastomosis-related complications. The proportion of weight lost 1 year after surgery was 8.8%. Our surgical procedure might be feasible for treating gastric cancer located in the upper third of the stomach or esophagogastric junction.

Precision surgical approach with lymph-node dissection in early gastric cancer

The gravest prognostic factor in early gastric cancer is lymph-node metastasis, with an incidence of about 10% overall. About two-thirds of early gastric cancer patients can be diagnosed as node-negative prior to treatment based on clinic-pathological data. Thus, the tumor can be resected by endoscopic submucosal dissection. In the remaining third, surgical resection is necessary because of the possibility of nodal metastasis. Nevertheless, almost all patients can be cured by gastrectomy with D1+ lymph-node dissection. Laparoscopic or robotic gastrectomy has become widespread in East Asia because perioperative and oncological safety are similar to open surgery. However, after D1+ gastrectomy, functional symptoms may still result. Physicians must strive to minimize post-gastrectomy symptoms and optimize long-term quality of life after this operation. Depending on the location and size of the primary lesion, preservation of the pylorus or cardia should be considered. In addition, the extent of lymph-node dissection can be individualized, and significant gastric-volume preservation can be achieved if sentinel node biopsy is used to distinguish node-negative patients. Though the surgical treatment for early gastric cancer may be less radical than in the past, the operative method itself seems to be still in transition.

Preservation of physiological passage through the remnant stomach prevents postoperative malnutrition after proximal gastrectomy with double tract reconstruction

PURPOSE

Double tract reconstruction (DT) after proximal gastrectomy (PG) is considered beneficial for postoperative nutrition status by preserving the physiological passage of food. We conducted this study to assess postoperative nutrition status based on food passage after this operation.

METHODS

The subjects of this retrospective study were 63 patients who underwent PG with DT. The patients were divided into two groups according to whether they had postoperative malnutrition (PM) 1 year postoperatively (PM group) or not (non-PM group). PM was defined by both weight loss > 10% and a low body mass index of < 20 or < 22 kg/m² for patients younger and older than 70 years, respectively. We then evaluated the predictors of PM.

RESULTS

There were 33 patients in the PM group. These patients were predominantly female (p < 0.01) and lacked physiological passage through the remnant stomach (PRS) on postoperative fluoroscopy (defined as non-PRS, p = 0.03). Multivariate logistic regression analysis revealed that female gender and non-PRS status were independent predictors of PM (odds ratio [95% CI]; 7.42 [1.33-41.4]; p = 0.02, 6.77 [1.01-45.4]; p = 0.04, respectively).

CONCLUSION

Preservation of the physiological passage of food through the remnant stomach prevents PM after PG with DT.

Multicenter retrospective study to evaluate the efficacy and safety of the double-flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD-FLAP Study)

AIM

As a result of the difficulty in effective prevention of gastroesophageal reflux, no standard reconstruction procedure after proximal gastrectomy (PG) has yet been established. The double-flap technique (DFT), or Kamikawa procedure, is an antireflux reconstruction procedure in esophagogastrostomy. The efficacy of DFT has recently been reported in several studies. However, these were all single-center studies with a limited number of cases.

METHODS

We conducted a multicenter retrospective study in which patients who underwent DFT, irrespective of disease type and reconstruction approach, at each participating institution between 1996 and 2015 were registered. Primary endpoint was incidence of reflux esophagitis at 1-year after surgery, and secondary endpoint was incidence of anastomosis-related complications.

RESULTS

Of 546 patients who were eligible for this study, 464 patients who had endoscopic examination at 1-year follow up were evaluated for reflux esophagitis. Incidence of reflux esophagitis of all grades was 10.6% and that of grade B or higher was 6.0%. Male gender and anastomosis located in the mediastinum/intra-thorax were independent risk factors for grade B or higher reflux esophagitis (odds ratio [OR]: 4.21, 95% confidence interval [CI]: 1.44-10.9, P = 0.0109). Total incidence of anastomosis-related complications was 7.2%, including leakage in 1.5%, strictures in 5.5% and bleeding in 0.6% of cases. Laparoscopic reconstruction was the only independent risk factor for anastomosis-related complications (OR: 3.93, 95% CI: 1.93-7.80, P = 0.0003).

CONCLUSION

Double-flap technique might be a feasible option after PG for effective prevention of reflux, although anastomotic stricture is a complication that must be well-prepared for.

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

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

BACKGROUND

Proximal gastrectomy offers theoretical benefits over total gastrectomy in terms of hematologic and nutritional outcomes. However, little evidence confirming these benefits has been reported. The aim of this study was to assess the hematologic and nutritional outcomes of proximal gastrectomy with double-tract reconstruction in comparison to those of total gastrectomy.

METHODS

We retrospectively analyzed data from 80 patients with stage I gastric cancer who underwent proximal gastrectomy with double-tract reconstruction (n = 38) or total gastrectomy (n = 42) from September 2014 to December 2015. We compared hematologic (including hemoglobin, ferritin, vitamin B₁₂, etc.) and nutritional outcomes [including body mass index (BMI), serum total protein, albumin, total cholesterol, and total lymphocyte count] between the two groups.

RESULTS

We found no significant differences in changes in hemoglobin (P = 0.250) or cumulative incidence of iron deficiency anemia (P = 0.971) during a median follow-up period of 24 months (range 18-30 months) after surgery. Cumulative incidence of vitamin B₁₂ deficiency also did not differ significantly between the proximal and total gastrectomy groups (P = 0.087). BMI changes from baseline were not significantly different between the two groups (P = 0.591). Likewise, there were no statistically significant differences in nutritional outcomes.

CONCLUSIONS

Proximal gastrectomy with double-tract reconstruction exhibited similar outcomes in terms of hematologic and nutritional features in comparison to total gastrectomy.