Long-Term Outcomes of Proximal Gastrectomy versus Total Gastrectomy for Upper-Third Gastric Cancer

Effect of Vitamin B12 Replacement Intervals on Clinical Symptoms and Laboratory Findings in Gastric Cancer Patients after Total Gastrectomy

The management of patients with vitamin B12 deficiency after total gastrectomy (TG) remains controversial. We aimed to evaluate the effect of vitamin B12 replacement intervals on the clinical characteristics in these patients. The data from patients who received vitamin B12 supplementation after TG between 2007 and 2018 at the National Cancer Center, Korea, were retrospectively evaluated. Vitamin B12 deficiency was defined as a serum vitamin B12 level of <200 pg/mL or urine methylmalonic acid level > 3.8 mg/gCr. The patients were divided into a regular replacement group (patients received an intramuscular injection or oral medication regularly), and a lab-based replacement group (patients received vitamin B12 intermittently after checking the level). The symptoms and biochemical parameters were compared between these groups. The regular and lab-based replacement groups included 190 and 216 patients, respectively. The median vitamin B12 replacement intervals were 1 and 9 months, respectively (p < 0.001). After replacement, the regular replacement group had higher vitamin B12 levels than the lab-based replacement group (p < 0.001). However, the serum hemoglobin level showed no significant changes. After replacement, there was no significant difference in the proportion of the symptomatic patients between the groups. Replacing vitamin B12 with a lab-based protocol may be sufficient for TG patients.

Outcomes of Proximal Versus Total Gastrectomy for Proximal Gastric Cancer: A Propensity Score-Matched Analysis of a Western Center Experience

PURPOSE

In this western study, we aimed to compare perioperative outcomes, postoperative complications, and overall survival in patients who underwent total gastrectomy (TG) or proximal gastrectomy (PG) for proximal gastric cancer (GC).

METHODS

Patients who underwent GC surgery at Marmara University Hospital between January 2014 and December 2021 were evaluated retrospectively. Propensity score matching (PSM) was performed to balance the baseline characteristics of patients undergoing PG and TG. Data on patients' demographics, clinicopathological features of tumors, complications, and survival rates were analyzed. Perioperative outcomes and overall survival of the patients were compared between PG and TG groups.

RESULTS

A total of 212 patients were included in this study, with 53 patients in the PG and 159 in the TG group. After 1:1 matching according to PSM, 46 patients in the PG group were matched to 46 in the TG group. After PSM, there were no differences in clinicopathological outcomes except retrieved lymph nodes. In terms of short-term outcomes, overall perioperative morbidity (Clavien Dindo ≥ 3a) was significantly higher in the PG group (p = 0.01). However, there was no significant difference when the complications were considered separately. In the long-term follow-up, reflux esophagitis was associated with the PG group (p=0.04). In multivariate analysis, positive surgical margin and lymphovascular invasion were significant factors related to overall survival. Overall, 5-year survival was 55% in matched patients. The difference in survival was not statistically significant (57 vs. 69 months, p = 0.3) between the two groups.

CONCLUSIONS

Proximal gastrectomy is applicable to patients up to stage 3 disease, with no difference in overall survival, with caution in early complications and reflux esophagitis. Among all demographic and oncological factors, lymphovascular invasion and resection margin were significantly associated with worse survival.

Proximal vs. Total Gastrectomy: Is There a Difference in Quality of Life for Patients?

BACKGROUND

Proximal gastrectomy (PG) has been excluded from the arsenal of western surgical oncologists for fear of bile reflux and diet intolerance. However, it is often an appropriate, less morbid operation for patients requiring resection of a proximal gastric cancer.

METHODS

Between 2013 and 2017, we performed 19 PG and 37 total gastrectomies (TGs), of whom 15 and 25 were alive at the time of data collection. In this single-center series, we present findings of a 10-question interview of patients who underwent proximal (n = 8) or TG (n = 16) regarding postgastrectomy food-related symptoms, based on a modified version of the validated Postgastrectomy Syndrome Assessment Scale.

RESULTS

Out of 7 Likert scale questions, there were no statistically significant differences between the groups regarding bile reflux, early satiety, appetite, energy level, physical activity limitations, pain, or general dissatisfaction with their surgery. Patients from both groups reported eating similar amounts of their preoperative volume per meal and overall food volume for the day. Both groups reported eating a similar number of snacks and meals throughout the day. Food satisfaction scores, calculated by summation of the Likert scores, were not different.

CONCLUSION

Although limited by the small population, we did not find a clinically relevant difference in food-related symptoms comparing PG and TG patients. This pilot study suggests that PG is an appropriate alternative to TG in certain populations. Anecdotal beliefs regarding potential bile reflux or diet intolerance should be reconsidered.

Surgery Matters: Progress in Surgical Management of Gastric Cancer

OPINION STATEMENT

The surgical treatment of gastric carcinoma has progressed significantly in the past few decades. A major milestone was the establishment of multimodal therapies for locally advanced tumours. Improvements in the technique of endoscopic resection have supplanted surgery in the early stages of many cases of gastric cancer. In cases in which an endoscopic resection is not possible, surgical limited resection procedures for the early stages of carcinoma are an equal alternative to gastrectomy in the field of oncology. Proximal gastrectomy is extensively discussed in this context. Whether proximal gastrectomy leads to a better quality of life and better nutritional well-being than total gastrectomy depends on the reconstruction chosen. The outcome cannot be conclusively assessed at present. For locally advanced stages, total or subtotal gastrectomy with D2 lymphadenectomy is now the global standard. A subtotal gastrectomy requires sufficiently long tumour-free proximal resection margins. Recent data indicate that proximal margins of at least 3 cm for tumours with an expansive growth pattern and at least 5 cm for those with an infiltrative growth pattern are sufficient. The most frequently performed reconstruction worldwide following gastrectomy is the Roux-en-Y reconstruction. However, there is evidence that pouch reconstruction is superior in terms of quality of life and nutritional well-being. Oncological gastric surgery is increasingly being performed laparoscopically. The safety and oncological equivalency were first demonstrated for early carcinomas and then for locally advanced tumours, by cohort studies and RCTs. Some studies suggest that laparoscopic procedures may be advantageous in early postoperative recovery. Robotic gastrectomy is also increasing in use. Preliminary results suggest that robotic gastrectomy may have added value in lymphadenectomy and in the early postoperative course. However, further studies are needed to substantiate these results. There is an ongoing debate about the best treatment option for gastric cancer with oligometastatic disease. Preliminary results indicate that certain patient groups could benefit from resection of the primary tumour and metastases following chemotherapy. However, the exact conditions in which patients may benefit have yet to be confirmed by ongoing trials.

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.

Proximal Gastrectomy Versus Total Gastrectomy for Siewert II/III Adenocarcinoma of the Gastroesophageal Junction: a Systematic Review and Meta-analysis

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has rapidly increased in recent years. Popular surgical approaches for AEG are proximal gastrectomy (PG) and total gastrectomy (TG), but it is controversial as to which approach is superior. Therefore, we conducted a systematic review and meta-analysis to evaluate the short- and long-term clinical outcomes of PG and TG for AEG.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to 1 June 2021. The Newcastle-Ottawa scale was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

RESULTS

In all, 1,734 patients with Siewert II/III AEG in 12 studies were included in the meta-analysis. PG was associated with less number of harvested lymph nodes (WMD =  - 9.00, 95% CI - 12.61 to - 5.39, P < 0.00001), smaller tumor size (WMD =  - 1.02, 95% CI - 1.71 to - 0.33, P = 0.004), shorter hospital length of stay (WMD =  - 3.99, 95% CI - 7.27 to - 0.71, P = 0.02), and better long-term nutritional status compared with TG. Overall complications, other complications, and overall survival were not significantly different between the two groups. Moreover, subgroup analysis revealed that the occurrence of anastomotic strictures and reflux esophagitis was associated with the use of novel gastrointestinal tract (GI) anastomoses (double-tract reconstruction, jejunal interposition, and semi-embedded valve anastomosis) after PG.

CONCLUSIONS

Based on the available evidence, we recommend that surgeons accept PG combined with multiple novel anastomoses as an optimal surgical approach in patients diagnosed with resectable Siewert type II/III AEG.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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

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

Proximal versus total gastrectomy for proximal gastric cancer: a Surveillance, Epidemiology, and End Results Program database analysis

Aims: To addresses whether surgical procedure (proximal gastrectomy [PG] vs total gastrectomy [TG]) influences survival outcomes. Methods: Patients were selected from Surveillance, Epidemiology and End Results Program (SEER) database. Survival curve was used to evaluate the differences in overall survival (OS) and cancer-specific survival (CSS). Results: No significant difference was detected in OS and CSS time between PG and TG groups. Also, no significant differences were observed in OS and CSS times between the two groups with respect to clinical stage, tumor stage, node stage, age, gender and tumor differentiation. Tumor differentiation, tumor size, tumor stage, node stage and age were independent prognostic factors in patients with proximal gastric cancer. Conclusions: TG was not necessary for proximal gastric cancer patients, and PG may be considered as an ideal surgery approach.

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.

Proximal gastrectomy with anti-reflux anastomosis for patients with adenocarcinoma of the esophagogastric junction: The simple and safe triangle-valve technique

A simple and safe triangle-valve technique (TVT) was applied in proximal gastrectomy (PG) in order to prevent postoperative gastric reflux among patients with adenocarcinoma of the esophagogastric junction (AEG). The clinical outcomes were evaluated in comparison to those of canonical total gastrectomy (TG). This retrospective study of 74 AEG patients compared two surgical procedures, PG-TVT (n=44) and TG (n=30), in terms of surgical outcomes, postoperative complications and nutritional status. The Reflux Disease Questionnaire (RDQ) was used to evaluate reflux esophagitis, and patients with an RDQ score of ≥12 points were diagnosed with gastroesophageal reflux disease (GERD). The mean operative time was significantly shorter in the PG-TVT group (242.6 min) compared with that in the TG group (288.1 min). The overall postoperative complication rate did not differ significantly between the PG-TVT and TG groups. All the patients were followed up for 6 months, and none developed cancer recurrence in distant organs, gastric remnant, or lymph nodes. The GERD incidence was similar between the PG-TVT and TG groups. The mean levels of total protein and albumin within 6 months were significantly higher in the PG-TVT group compared with those in the TG group after adjustingtthe time effect and the interaction of time and surgical methods. The level of total protein significantly increased within 6 months in the PG-TVT group, but decreased in the TG group. Therefore, PG-TVT has several advantages over TG for patients with AEG, including a shorter operative time and better postoperative nutritional status, whereas the incidence of GERD was found to be similar between the two techniques.

Proximal gastrectomy versus total gastrectomy for adenocarcinoma of the esophagogastric junction: a meta-analysis

Aim: To compare efficacy between total gastrectomy (TG) and proximal gastrectomy (PG) for upper-third gastric cancer. Materials & methods: PubMed, Embase and Cochrane library were searched to select suitable researches. Stata was used for meta-analysis including 5-year overall survival rate, recurrence rate, complication morbidities and serum nutritional levels. Results: Ten retrospective English researches were contained. Our study showed no significant difference of 5-year overall survival rate, recurrence rate, reflux symptoms and anastomotic leakage. TG experienced longer operation time, more lymph nodes-retrieved number, more estimated blood loss and higher ileus, but less anastomotic stricture. PG showed advantages over TG in terms of serum nutritional levels. Conclusion: PG is more preferable to TG for treatment of upper-third gastric cancer.

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

BACKGROUND

Recently, the incidence of proximal early gastric cancer (EGC) has been rising rapidly. Prevalent surgical methods are proximal gastrectomy (PG) and total gastrectomy (TG); however, which method is superior remains controversial. We conducted a systematic review and meta-analysis of original articles to compare the short- and long-term clinical outcomes of PG with TG for proximal EGC.

METHODS

Databases, including PubMed, Embase, Web of Science, and Cochrane Library were searched up to October 2018. The Newcastle-Ottawa scale was utilized to conduct quality assessments, and publication bias was evaluated using Egger test. STATA version 14.0 was used to perform the meta-analysis.

RESULTS

A total of 2036 patients with proximal EGC in 18 studies were included in the meta-analysis. The results showed that PG was potentially superior to TG regarding operation time, intraoperative blood loss volume, and long-term nutritional status. Overall survival between the PG and TG groups was not significantly different. PG was associated with a high incidence of 2 kinds of postoperative complications: anastomotic stenosis and reflux esophagitis. However, the incidence of these complications associated with esophagojejunostomy with double-tract reconstruction (DTR) was comparable with that of TG.

CONCLUSIONS

PG has several advantages over TG for the treatment of proximal EGC, including surgical outcomes and long-term nutritional status. However, anastomotic stenosis and reflux esophagitis frequently occurred in patients undergoing PG. Esophagojejunostomy with DTR could offer a solution to reducing the incidence of these complications.

What Is the Best Operation for Proximal Gastric Cancer and Distal Esophageal Cancer?

Cancer of the gastroesophageal junction (GEJ) is increasing in incidence, likely as a result of rising obesity and gastroesophageal reflux disease rates. The tumors that arise here share features of esophageal and gastric cancer, and are classified based on their location in relationship to the GEJ. The definition of the GEJ itself, as well as optimal resection strategy, extent of lymph node dissection, resection margin length, and reconstruction methods are still very much a subject of debate. This article summarizes the available evidence on this topic, and highlights specific areas for further research.

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.

Clinical Outcomes of Gastric Cancer Patients Who Underwent Proximal or Total Gastrectomy: A Propensity Score-Matched Analysis

BACKGROUND

Total gastrectomy (TG) and proximal gastrectomy (PG) are used to treat upper-third early gastric cancer. To date, no consensus has been reached regarding which procedure should be selected. The aim of this study was to validate the usefulness of preserving the stomach in early upper-third gastric cancer.

METHODS

Between 2004 and 2013, 201 patients underwent PG or TG at our institution for treatment of upper-third early gastric cancer. According to the defined inclusion and exclusion criteria, 192 cases were enrolled in this study. One-to-one propensity score matching was performed to compare the outcomes between the two groups.

RESULTS

The operation time was shorter in the PG group. Although no significant difference was observed, the PG group had less bleeding and fewer postoperative complications. R0 resection rate was 100%, and no surgery-related deaths were observed. The frequencies of reflux symptoms and anastomotic stenosis were significantly higher in the PG group, but could be controlled by balloon dilation and drug therapy. The maintenance rates of body mass index and lean body mass were significantly higher in patients who underwent PG than TG. The total protein and serum albumin values were higher in the PG group than in the TG group and remained statistically superior.

CONCLUSION

PG group exhibited better perioperative performance. Furthermore, better nutritional results were obtained in the PG group. Although the late stenosis and reflux symptoms must be addressed, the PG is a preferable surgical procedure for the treatment of early proximal gastric cancer.

Total vs proximal gastrectomy for adenocarcinoma of the upper third of the stomach: a propensity-score-matched analysis of a multicenter western experience (On behalf of the Italian Research Group for Gastric Cancer-GIRCG)

BACKGROUND

The aim of this study is to compare surgical outcomes including postoperative complications and prognosis between total gastrectomy (TG) and proximal gastrectomy (PG) for proximal gastric cancer (GC). Propensity-score-matching analysis was performed to overcome patient selection bias between the two surgical techniques.

METHODS

Among 457 patients who were diagnosed with GC between January 1990 and December 2010 from four Italian institutions, 91 underwent PG and 366 underwent TG. Clinicopathologic features, postoperative complications, and survivals were reviewed and compared between these two groups retrospectively.

RESULTS

After propensity-score matching had been done, 150 patients (75 TG patients, 75 PG patients) were included in the analysis. The PG group had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the TG group. N stages and 5-year survival rates were similar after TG and PG. Postoperative complication rates after PG and TG were 25.3 and 28%, respectively, (P = 0.084). Rates of reflux esophagitis and anastomotic stricture were 12 and 6.6% after PG and 2.6 and 1.3% after TG, respectively (P < 0.001 and P = 0.002). 5-year overall survival for PG and TG group was 56.7 and 46.5%, respectively (P = 0.07). Survival rates according to the tumor stage were not different between the groups. Multivariate analysis showed that type of resection was not an independent prognostic factor.

CONCLUSION

Although PG for upper third GC showed good results in terms of survival, it is associated with an increased mortality rate and a higher risk of reflux esophagitis and anastomotic stricture.

Linear-Stapled Side-to-Side Esophagojejunostomy with Hand-Sewn Closure of the Common Enterotomy After Prophylactic and Therapeutic Total Gastrectomy

After total gastrectomy, anastomosis-related complications such as leak or stricture can be highly morbid. Between July 2005 and December 2015, a linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy (modified Orringer technique) was used for Roux-en-Y reconstruction after prophylactic total gastrectomy in 22 germline CDH1 mutation carriers and after therapeutic total gastrectomy in 18 patients diagnosed with gastric adenocarcinoma. All operations were performed by the same surgeon. No patient in either cohort developed a clinically evident anastomotic leak, one patient (2.5%) developed a contained radiographic leak that healed without intervention, and one patient (2.5%) developed an anastomotic stricture treated by endoscopic dilatation 7 months after operation. These rates were lower than radiographic leak and stricture rates in a comparison group of 32 patients who received a completely hand-sewn esophagojejunostomy (6.3 and 3.1%, respectively). Here, we describe how to perform the linear-stapled esophagojejunostomy anastomosis.

Quality of life: A critical outcome for all surgical treatments of gastric cancer

Surgery represents the main curative therapeutic modality for gastric cancer, and it is occasionally considered for palliation as well as prophylaxis. Most frequently, surgical outcomes are conveyed in terms of oncological outcomes such as recurrence and survival. However, quality of life (QoL) is also important and should be considered when making treatment decisions - including the extent of and approach to surgery. Measurement of QoL usually involves the application of questionnaires. While there are multiple QoL questionnaires validated for use in oncology patients, there are very few that have been validated for use in those with gastric cancer. In this review, we discuss and compare the current status of QoL questionnaires in gastric cancer. More importantly, the impact of surgery for treatment, palliation and prophylaxis of gastric cancer on QoL will be described. These data should inform the surgeon on the optimal approach to treating gastric cancer, taking into account oncological outcomes. Knowledge gaps are also identified, providing a roadmap for future studies.

Laparoscopic gastric cancer surgery: Current evidence and future perspectives

Laparoscopic gastrectomy has been widely accepted as a standard alternative for the treatment of early-stage gastric adenocarcinoma because of its favorable short-term outcomes. Although controversies exist, such as establishing clear indications, proper preoperative staging, and oncologic safety, experienced surgeons and institutions have applied this approach, along with various types of function-preserving surgery, for the treatment of advanced gastric cancer. With technical advancement and the advent of state-of-the-art instruments, indications for laparoscopic gastrectomy are expected to expand as far as locally advanced gastric cancer. Laparoscopic gastrectomy appears to be promising; however, scientific evidence necessary to generalize this approach to a standard treatment for all relevant patients and care providers remains to be gathered. Several multicenter, prospective randomized trials in high-incidence countries are ongoing, and results from these trials will highlight the short- and long-term outcomes of the approach. In this review, we describe up-to-date findings and critical issues regarding laparoscopic gastrectomy for gastric cancer.

Potential benefits of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy for cT1 upper-third gastric cancer

BACKGROUND

Few reports have compared laparoscopy-assisted proximal gastrectomy (LAPG) with laparoscopy-assisted total gastrectomy (LATG) in patients with cT1N0 gastric cancer. This study assessed the safety and feasibility of LAPG with esophagogastrostomy in these patients and compared postgastrectomy disturbances and nutritional status following LAPG and LATG.

METHODS

This study compared 40 patients who underwent LAPG with esophagogastrostomy and 59 who underwent LATG with esophagojejunostomy, both with OrVil™. Surgical outcomes, postoperative complications, nutritional status at 1 and 2 years, and relapse-free survival were compared in these two groups.

RESULTS

Operation time was significantly shorter in the LAPG group than in the LATG group (280 min vs. 365 min, P < 0.001). Although the rate of surgical complications was similar in the two groups, the rate of anastomotic stricture was significantly higher in the LAPG group than in the LATG group (28 vs. 8.4 %; P = 0.012). Rates of reflux esophagitis graded A or higher in the Los Angeles classification were 10 and 5.1 %, respectively. Hemoglobin levels 2 years after surgery, relative to baseline levels, were significantly higher in the LAPG group than in the LATG group (98.6 vs. 92.9 %, P = 0.020). Body weight, albumin and total protein concentrations, and total lymphocyte count 1 and 2 years after surgery were slightly, but not significantly, higher in the LAPG group. Relapse-free survival rates were similar, as were 5-year overall survival rates (86 vs. 79 %, P = 0.42).

CONCLUSIONS

LAPG with esophagogastrostomy using OrVil™ was safe and feasible for patients with cT1N0 gastric cancer. LAPG may have nutritional advantages over LATG, but the rate of anastomotic stricture was significantly higher for LAPG than for LATG.