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

A multi-center, prospective, clinical study to evaluate the anti-reflux efficacy of laparoscopic double-flap technique (lD-FLAP Study)

Background

Double-flap technique (DFT) is a reconstruction procedure after proximal gastrectomy (PG). We previously reported a multi-center, retrospective study in which the incidence of reflux esophagitis (RE) (Los Angeles Classification ≥Grade B [LA-B]) 1 year after surgery was 6.0%. There have been many reports, but all of them were retrospective. Thus, a multi-center, prospective study was conducted.

Methods

Laparoscopic PG + DFT was performed for cT1N0 upper gastric cancer patients. The primary endpoint was the incidence of RE (≥LA-B) 1 year after surgery. The planned sample size was 40, based on an estimated incidence of 6.0% and an upper threshold of 20%.

Results

Forty patients were recruited, and 39, excluding one with conversion to total gastrectomy, received protocol treatment. Anastomotic leakage (Clavien-Dindo ≥Grade III) was observed in one patient (2.6%). In 38 patients, excluding one case of postoperative mortality, RE (≥LA-B) was observed in two patients (5.3%) 1 year after surgery, and the upper limit of the 95% confidence interval was 17.3%, lower than the 20% threshold. Anastomotic stricture requiring dilatation was observed in two patients (5.3%). One year after surgery, body weight change was 88.9 ± 7.0%, and PNI <40 and CONUT ≥5, indicating malnutrition, were observed in only one patient (2.6%) each. In the quality of life survey using the PGSAS-45 questionnaire, the esophageal reflux subscale score was 1.4 ± 0.6, significantly better than the public data (2.0 ± 1.0; p = 0.001).

Conclusion

Laparoscopic DFT showed anti-reflux efficacy. Taken together with the acceptable incidence of anastomotic stricture, DFT can be an option for reconstruction procedure after PG.

Gastric Cancer Surgery: Balancing Oncological Efficacy against Postoperative Morbidity and Function Detriment

Significant progress has been made in the surgical management of gastric cancer over the years, and previous discrepancies in surgical practice between different parts of the world have gradually lessened. A transition from the earlier period of progressively more extensive surgery to the current trend of a more tailored and evidence-based approach is clear. Prophylactic resection of adjacent anatomical structures or neighboring organs and extensive lymph node dissections that were once assumed to increase the chances of long-term survival are now performed selectively. Laparoscopic gastrectomy has been widely adopted and its indications have steadily expanded, from early cancers located in the distal part of the stomach, to locally advanced tumors where total gastrectomy is required. In parallel, function-preserving surgery has also evolved and now constitutes a valid option for early gastric cancer. Pylorus-preserving and proximal gastrectomy have improved the postoperative quality of life of patients, and sentinel node navigation surgery is being explored as the next step in the process of further refining the minimally invasive concept. Moreover, innovative techniques such as indocyanine green fluorescence imaging and robot-assisted gastrectomy are being introduced in clinical practice. These technologies hold promise for enhancing surgical precision, ultimately improving the oncological and functional outcomes.

Differences in glycemic trends due to reconstruction methods after proximal gastrectomy from the perspective of continuous glucose-monitoring

PURPOSE

In recent years, clinicians have focused on the importance of preventing hypoglycemia. We evaluated the impact of different reconstruction procedures after proximal gastrectomy on glycemic variability in non-diabetic patients with gastric cancer.

METHODS

This prospective observational study was conducted between April 2020 and March 2023. Flash continuous glucose-monitoring, a novel method for assessing glycemic control, was used to evaluate the glycemic profiles after gastrectomy. A flash continuous glucose-monitoring sensor was placed subcutaneously at the time of discharge, and glucose trends were evaluated for 2 weeks.

RESULTS

The anastomotic methods for proximal gastrectomy were esophagogastrostomy in 10 patients and double-tract reconstruction in 10 patients. The time below this range (glucose levels < 70 mg/dL) was significantly higher in the double-tract reconstruction group than in the esophagogastrostomy group (p = 0.049). A higher nocturnal time below this range was significantly correlated with an older age and double-tract reconstruction (p = 0.025 and p = 0.025, respectively).

CONCLUSION

These findings provide new insights into reconstruction methods after proximal gastrectomy by assessing postoperative hypoglycemia in non-diabetic patients with gastric cancer.

Safety and short-term outcomes of a modified valvuloplastic esophagogastrostomy versus gastric tube anastomosis after laparoscopy-assisted proximal gastrectomy: a retrospective cohort study

BACKGROUND

There is no optimal reconstruction method after proximal gastrectomy. The valvuloplastic esophagogastrostomy can reduce postoperative reflux esophagitis, but it is technically complex with a long operation time. The gastric tube anastomosis is technically simple, but the incidences of reflux esophagitis and anastomotic stricture are higher.

METHODS

We have devised a modified valvuloplastic esophagogastrostomy after laparoscopy-assisted proximal gastrectomy (LAPG), the arch-bridge anastomosis. After reviewing our prospectively maintained gastric cancer database, 43 patients who underwent LAPG from November 2021 to April 2023 were included in this cohort study, with 25 patients received the arch-bridge anastomosis and 18 patients received gastric tube anastomosis. The short-term outcomes were compared between the two groups to evaluate the efficacy of the arch-bridge anastomosis. Reporting was consistent with the STROCSS 2021 guideline.

RESULTS

The median operation time was 180 min in the arch-bridge group, significantly shorter than the gastric tube group (p = 0.003). In the arch-bridge group, none of the 25 patients experienced anastomotic leakage, while one patient (4%) experienced anastomotic stricture requiring endoscopic balloon dilation. The postoperative length of stay was shorter in the arch-bridge group (9 vs. 11, p = 0.034). None of the patients in the arch-bridge group experienced gastroesophageal reflux and used proton pump inhibitor (PPI), while four (22.2%) patients in the gastric tube group used PPI (p = 0.025). The incidence of reflux esophagitis (Los Angeles grade B or more severe) by endoscopy was lower in the arch-bridge group (0% vs. 25.0%).

CONCLUSION

The arch-bridge anastomosis is a safe, time-saving, and feasible reconstruction method. It can reduce postoperative reflux and anastomotic stricture incidences in a selected cohort of patients undergoing laparoscopy-assisted proximal gastrectomy.

Clinical efficacy of modified Kamikawa anastomosis in patients with laparoscopic proximal gastrectomy

BACKGROUND

With the increasing incidence of proximal gastric cancer, laparoscopic proximal gastrectomy has been applied. However, reflux esophagitis often occurs after traditional esophagogastric anastomosis. In order to solve this problem, several methods of digestive tract reconstruction have emerged, but the most satisfying method remains to be discussed. Therefore, we modified traditional Kamikawa anastomosis to investigate the appropriate digestive tract reconstruction in laparoscopic proximal gastrectomy.

AIM

To discuss the clinical efficacy of modified Kamikawa anastomosis in laparoscopic proximal gastrectomy.

METHODS

A retrospective case series was adopted. Clinicopathological data were collected from 26 patients who underwent laparoscopic proximal gastrectomy and modified Kamikawa anastomosis at our hospital from January 2020 to September 2022. The operation conditions, postoperative recovery, postoperative complications, and follow-up data were collected and analyzed.

RESULTS

All the patients were successfully operated on without conversion to laparotomy. The duration of operation and digestive tract reconstruction were 203.500 (150-224) min and 87.500 (73-111) min, respectively. The intraoperative amount of bleeding was 20.500 mL ± 0.696 mL. The time of postoperative first flatus, the first postoperative fluid intake, and the postoperative length of stay were 2 (1-3) d, 4 (3-5) d, and 9 (8-10) d, respectively. All the patients were followed up for 12-23 months. The body mass index at 6 and 12 months after surgery were 22.577 kg/m2 ± 3.098 kg/m2 and 22.594 kg/m2 ± 3.207 kg/m2, respectively. The nutrition risk screening 2002 score, the patient-generated subjective global assessment score, and the gastroesophageal reflux disease scale score were good at 6 and 12 months after surgery. Reflux esophagitis and anastomotic stenosis were not observed in any of the patients during their 12-month postoperative gastroscopy or upper gastrointestinal tract visits. All the patients exhibited no tumor recurrence or metastasis.

CONCLUSION

The modified Kamikawa anastomosis is safe and feasible for laparoscopic proximal gastrectomy and has good antireflux effects and nutritional status.

Comparison of proximal gastrectomy with double-flap technique and double-tract reconstruction for proximal early gastric cancer: a meta-analysis

Surgical resection is the main treatment for proximal gastric cancer, but there is no consensus on its reconstruction. We carried out a meta-analysis to evaluate the effects of double-tract reconstruction (DTR) and double-flap technique (DFT) on postoperative quality of life in patients with proximal gastric cancer. Systematic searches of PubMed, Web of Science, EBSCO, and the Cochrane Library were performed. Literature for the last 5 years was searched without language restrictions. The cutoff date for the search was 12 April 2023. Literature and research searches were conducted independently by two researchers and data were extracted. Statistical analyses were performed using Review Manager (Revman) 5.4 software. Fixed models were used when heterogeneity was small and random-effects models were used for meta-analysis when heterogeneity was large. The study was registered with PROSPERO, CRD 42023418520. Surgical time was significantly shorter in the DTR group than in the DFT group (P = 0.03). There were no significant differences between DFT and DTR in terms of age, gender, pathological stage, preoperative body mass index, surgical bleeding, and perioperative complications. There was no statistically significant difference between the two groups in terms of reflux esophagitis and PPI intake, but DFT was superior to DTR in weight improvement at 1 year after surgery (P < 0.0001). Compared with DTR, DFT reconstruction is more demanding and time-consuming, but its postoperative nutritional status is better, so it should be the first choice for GI reconstruction in most patients with early proximal gastric cancer. However, DTR should be the best choice for patients who have difficulty operating.

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.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

A Novel Esophagogastrostomy Technique for Laparoscopic Proximal Gastrectomy: Conical Remnant Gastroesophageal Side-overlap Fundoplication

Background

There is currently no universally-accepted, ideal method of esophagogastric reconstruction to address reflux esophagitis and anastomotic complications of esophagogastrostomy after proximal gastrectomy.

Case Report

In June 2022, two patients with Siewert type II carcinoma of esophagogastric junction underwent laparoscopic proximal gastrectomies, using a novel esophagogastrostomy technique of Conical remnant GastroEsophageal side-Overlap fundoplication (CGEO). On postoperative day 4, upper gastrointestinal fluoroscopy was performed, with patients in downward and left oblique positions, allowing gastrografin to accumulate within fundic reconstructions. No reflux into the esophagus was subsequently observed, and both patients were discharged (postoperative days 9 and 11). Six months after surgery, endoscopic view showed that the reconstructed cardia returned to its normal state, in the absence of any reflux symptoms. As of April 2023, we have operated on four patients using CGEO, and all of them recovered without obvious reflux symptoms.

Conclusion

CGEO is a feasible and safe reconstructive esophagogastrostomy procedure following laparoscopic proximal gastrectomy for Siewert type II esophagogastric junction carcinoma.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND

Reflux esophagitis is a common postoperative complication of proximal gastrectomy. There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy. We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis (EGAA) can prevent postoperative reflux in a safe and feasible manner.

AIM

To observe a novel method of EGAA to prevent postoperative reflux.

METHODS

Initially, we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis. This was done in order to better understand the anti-reflux function and mechanism. Next, we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy. Post-surgery, we monitored the structure and function of the reconstruction through imaging exams and gastroscopy. Finally, the patients were followed up to assess the efficacy of the anti-reflux effects.

RESULTS

Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma, providing a means to prevent the reverse flow of gastric fluids. Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy, with a mean operation time of 304.2 ± 44.3 min. After the operation, the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux, three had mild reflux, and two had obvious reflux. The abdominal computed tomography examination showed a valve-like structure at the anastomosis. During follow-up, gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients. Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.

CONCLUSION

EGAA is a feasible and safe surgical method, with an excellent anti-reflux effect after proximal gastrectomy.

Anastomotic stenosis following proximal gastrectomy with single flap valvulopasty successfully managed with endoscopic stricturotomy: a case report

Background

Due to its nutritional advantages over total gastrectomy, proximal gastrectomy (PG) with anti-reflux techniques has gained significant attention in East Asian countries in recent years. The double flap technique (DFT) and modified side overlap and fundoplication by Yamashita (mSOFY) are two promising anti-reflux interventions following PG. However, anastomotic stenosis after DFT and gastroesophageal reflux after mSOFY have been reported in several patients. To address these concerns, a hybrid reconstruction procedure was designed, namely, right-sided overlap with single flap valvulopasty (ROSF), for proximal gastrectomy, with the aim of reducing anastomotic stricture and reflux. Among the 38 patients who underwent ROSF at our hospital, one developed Stooler grade II anastomotic stenosis. Herein, we present the successful management of this patient through endoscopic stricturotomy (ES).

Case summary

A 72-year-old female complaining of "epigastric pain and discomfort for more than 1 month" was diagnosed with adenocarcinoma of the esophagogastric junction (Siewert type II). She underwent laparoscopic-assisted PG and ROSF procedures at our hospital and recovered well after surgery. However, she started experiencing progressive difficulty in eating and vomiting approximately 3 weeks after the intervention. Endoscopy revealed Stooler grade II esophagogastric anastomotic stenosis. ES with insulated tip (IT) Knife nano was eventually performed, and the patient was able to resume a normal diet without experiencing any discomfort during the 5-month follow-up period.

Conclusion

Endoscopic stricturotomy using IT Knife nano successfully treated anastomotic stenosis following ROSF with no associated complications. Thus, ES to treat anastomotic stenosis after PG with valvulopasty can be considered a safe option and should be performed in centers with the required expertise.

A sandwiching method that simplifies hepatic left lateral segment inversion to secure an optimal surgical view around the esophageal hiatus in laparoscopic and robotic gastrectomy for upper gastric and esophagogastric junction cancers

PURPOSE

In laparoscopic surgery for upper gastric and esophagogastric junction (EGJ) cancer, it is important to achieve optimal exposure of the esophageal hiatus to secure an appropriate workspace. In recent years, hepatic left lateral segment (HLLS) inversion has been used to achieve an optimal surgical field. We present a simple technique to perform a modified HLLS inversion.

METHODS

As a simple modified method, suturing a 2-0 straight needle to the peritoneum of the round ligament and pulling it to the outside of the abdominal cavity, the falciform, left triangular, and coronary ligaments were dissected. The HLLS was inverted by moving it to the right through the space of the transected falciform ligament. By ligating the thread through the round ligament, the HLLS was sandwiched between the rest of the liver and abdominal wall. The short-term surgical outcomes of patient who underwent simple modified HLLS inversion were retrospectively reviewed.

RESULTS

This study investigated consecutive 24 patients who underwent laparoscopic proximal and total gastrectomies using the simple modified HLLS inversion technique between June 2021 and April 2022. This series of procedures could be completed in approximately 16 min. A Nathanson liver retractor was used in three patients due to difficulties in completing the HLLS inversion in our institution. Postoperative serum liver enzyme levels indicated there was a small effect on the liver.

CONCLUSIONS

The simple modified HLLS inversion technique may be a safe and useful procedure and can provide an enhanced surgical field during laparoscopic surgery for upper gastric and EGJ cancers.

Laparoscopic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (ROSF): a case-series study

BACKGROUND

There is no standard reconstruction method following proximal gastrectomy, of which gastroesophageal reflux and anastomotic complications are of great concern. Though several techniques have been devised to overcome these postoperative complications, such as double tract reconstruction, double-flap technique and side overlap fundoplication by Yamashita, none of them is considered a perfect solution. Herein, we designed a novel method of esophagogastrostomy after laparoscopic proximal gastrectomy (LPG), named right-sided overlap and single-flap valvuloplasty (ROSF).

METHODS

Between March 2021 and December 2021, 20 consecutive patients underwent LPG-ROSF at Department of Gastrointestinal Surgery, Second Affiliated Hospital of Soochow University. Surgical outcomes and postoperative complications were recorded. All patients were followed-up until December 2022. Endoscopy and assessment of gastrointestinal symptoms were performed 1 year after surgery. Nutrition-related parameters including total body weight, hemoglobin, lymphocyte count, serum total protein, serum albumin and serum prealbumin were evaluated 1 year after surgery and compared with those before surgery.

RESULTS

The mean surgery time and anastomosis time was 285.3 ± 71.3 and 61.3 ± 11.2 min respectively. None of the patients had gastrointestinal early postoperative complications. Symptomatic reflux was observed in one patient (5%) while reflux esophagitis (Los Angeles Grade A) was observed in another patient (5%). Four patients (20%) had mild dysphagia (Visick score = II) but none of them had anastomotic stenosis. There were no significant changes in nutritional status postoperatively.

CONCLUSIONS

ROSF can be safely performed after LPG and has satisfactory outcomes in preventing reflux and stenosis, and maintaining nutritional status. This technique requires further validation.

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.

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.

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.

Comparison of changes in body-fat mass and reflux esophagitis among reconstruction methods for proximal gastrectomy

BACKGROUND

Although proximal gastrectomy (PG) is a function-preserving surgical option, it remains unclear as to which reconstruction method can prevent reflux and maintain body composition.

METHODS

Patients who underwent PG at Keio University between April 2011 and November 2018 were analyzed. Changes in the subcutaneous and visceral adipose tissues were comparatively assessed before and after a year of surgery for three common reconstruction methods. We also compared the endoscopic findings of reflux esophagitis and the number of patients prescribed with proton-pump inhibitor after a year of surgery.

RESULTS

This study included 76 patients, of which 33 patients underwent esophagogastrostomy with a circular stapler (CS), 35 under double flap (DF) reconstruction, and 8 underwent double tract (DT) reconstruction. Comparing esophagogastrostomy (CS and DF) and DT showed that esophagogastrostomy could significantly preserve both subcutaneous and visceral adipose tissues (P < 0.001 and P = 0.04, respectively). However, the change in the subcutaneous and visceral adipose tissues was comparable between CS and DF. As for reflux esophagitis, DF showed the lowest incidence rate for esophagitis and the least number of patients who were prescribed a proton-pump inhibitor.

CONCLUSION

DF is a relatively better reconstruction method for preserving fat mass and preventing reflux among the three common reconstruction methods.

Mediastinal Lymph Node Dissection in Gastroesophageal Junction Adenocarcinoma

Currently, the prevalence of gastroesophageal junction adenocarcinoma (GEJAC) is increasing in both Asian and Western countries, although the increasing rate in Asian countries is much slower than in Western countries. With these current trends, concerns regarding the surgical treatment method are also increasing among gastrointestinal surgeons. However, the surgical treatment for GEJAC has been a controversial issue for a long time due to the relative scarcity of this tumor and its characteristics from its borderline location. Recently, a large-scale prospective study of this tumor has been conducted in Japan, and the results are now available. The results of this study will be helpful for understanding this tumor. In this article, the pattern of lymph node metastasis of GEJAC is reviewed, and the extent and method of lymph node dissection for this tumor are discussed and proposed based on the review.

Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis

BACKGROUND

Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis.

METHODS

A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher.

RESULTS

The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011).

CONCLUSIONS

There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm.

Cardia function-preserving surgery and anti-reflux anastomotic method after proximal gastrectomy for gastric cancer: Current status and future perspectives

The incidence and mortality of gastric cancer ranked 5th and 3rd worldwide, respectively, in 2018, and the incidence of gastroesophageal junction adenocarcinoma increased over the past 40 years. Radical resection and lymph node dissection is the preferred treatment for gastric cancer. Proximal gastrectomy or total gastrectomy is usually performed for gastroesophageal junction adenocarcinoma and upper gastric cancer. Owing to the resection of the cardia structures, the incidence of reflux esophagitis increases significantly after proximal gastrectomy and total gastrectomy, resulting in poor postoperative quality of life. To reduce the incidence of reflux esophagitis and improve patients' postoperative quality of life, various methods to preserve the function of the cardia or to perform anti-reflux reconstruction have emerged. In this manuscript, we systematically introduced the advantages and problems of various anti-reflux anastomotic method after proximal gastrectomy, and cardia-preserving gastrectomy including endoscopic resection (ER), local gastrectomy by gastroscopy combined with laparoscopy, segmental gastrectomy, subtotal gastrectomy, and cardia-preserving radical gastrectomy. Cardia-preserving radical gastrectomy has the advantage of more thorough lymph node dissection and wider indications than those for subtotal gastrectomy. However, the clinical efficacy of cardia-preserving radical gastrectomy requires verification in prospective and controlled clinical trials. Cardia-preserving radical gastrectomy is a promising approach as one of the more reasonable anti-reflux surgeries.

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.

Simple modifications of conventional esophagogastrostomy after proximal gastrectomy adequately reduces the postoperative reflux esophagitis: a retrospective analysis of posterolateral fundoplication

PURPOSE

While proximal gastrectomy is being performed increasingly frequently for the treatment of gastric cancer, a standard reconstruction method to obtain optimal postoperative quality of life (QOL) still remains to be established. We modified the original esophagogastrostomy technique by introducing an additional posterolateral fundoplication (PLF) technique to minimize the risk of reflux esophagitis in patients undergoing proximal gastrectomy. The aim of this study was to clarify the clinical benefit of PLF.

METHODS

A retrospective analysis of the database was conducted to evaluate the effects of PLF. The data were compared between 44 patients in whom PLF was performed (PLF group) and 17 patients in whom conventional esophagogastrostomy without PLF was performed (C group). A number of incidence of postoperative reflux esophagitis and symptoms were assessed by findings of endoscopic examination and the PGSAS-45 questionnaire, respectively.

RESULTS

The incidence of grade B or worse esophagitis after surgery was significantly lower in the PLF group than in the C group (0% vs. 58.8%, P < 0.01). The score for the esophageal reflux subscale, as the main outcome measure of PGSAS-45, was significantly better in the PLF group (PLF: 1.5 vs C: 2.4, P < 0.01). Cohen's d value was 1.75, which suggested a rather large effect size. Postoperative benign anastomotic stricture was encountered in 10 cases (22.7%) of the PLF group and 4 cases (23.5%) of the C group, all of whom were successfully treated by brief endoscopic mechanical dilatation.

CONCLUSION

PLF is an expedient procedure for reconstruction after proximal gastrectomy.

Impact of Tumor Location on the Quality of Life of Patients Undergoing Total or Proximal Gastrectomy

Purpose

Most studies have investigated the differences in postgastrectomy quality of life (QOL) based on the surgical procedure or reconstruction method adopted; only a few studies have compared QOL based on tumor location. This large-scale study aims to investigate the differences in QOL between patients with esophagogastric junction cancer (EGJC) and those with upper third gastric cancer (UGC) undergoing the same gastrectomy procedure to evaluate the impact of tumor location on postoperative QOL.

Methods

The Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire was distributed in 70 institutions to 2,364 patients who underwent gastrectomy for EGJC or UGC. A total of 1,909 patients were eligible for the study, and 1,744 patients who underwent total gastrectomy (TG) or proximal gastrectomy (PG) were selected for the final analysis. These patients were divided into EGJC and UGC groups; thereafter, the PGSAS-45 main outcome measures (MOMs) were compared between the two groups for each type of gastrectomy.

Results

Among the post-TG patients, only one MOM was significantly better in the UGC group than in the EGJC group. Conversely, among the post-PG patients, postoperative QOL was significantly better in 6 out of 19 MOMs in the UGC group than in the EGJC group.

Conclusions

Tumor location had a minimal effect on the postoperative QOL of post-TG patients, whereas among post-PG patients, there were definite differences in postoperative QOL between the two groups. It seems reasonable to conservatively estimate the benefits of PG in patients with EGJC compared to those in patients with UGC.

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.

Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction

PURPOSE

Despite the increasing incidence of adenocarcinoma of the esophagogastric junction, laparoscopic proximal gastrectomy with lower esophagectomy (PGLE) is not widely accepted owing to the lack of standardized reconstruction techniques. In this study, we developed a new reconstruction method named y-shaped overlap esophagogastric tube reconstruction, which reproduces an angle of His and a pseudo-fornix, to be used in laparoscopic transhiatal PGLE. This study aimed to determine the feasibility of this novel reconstruction method.

METHODS

This retrospective study included the analysis of short- and mid-term surgical outcomes of 30 consecutive patients with Siewert type II esophagogastric junction adenocarcinoma who underwent laparoscopic PGLE with y-shaped overlap esophagogastric tube reconstruction from April 2015 to August 2020. A novel method was used to form a 6-cm pseudo-fornix and an angle of His using the distal esophagus and a long gastric tube.

RESULTS

The median operation time was 369 min, and the median blood loss was 28 mL. The median follow-up period after surgery was 37 months. Although two patients experienced postoperative anastomotic leakage, none of the patients developed stenosis. One patient experienced moderate reflux symptoms, whereas four patients developed moderate reflux esophagitis based on the 1-year follow-up endoscopic examination; the condition of all patients could be efficiently controlled with medication.

CONCLUSION

The short- and mid-term surgical outcomes of y-shaped overlap esophagogastric tube reconstruction reflected the feasibility of this simple technique and suggested its potential utility as a reconstruction alternative for Siewert type II tumors.

Spade-Shaped Anastomosis after Laparoscopic Proximal Gastrectomy Using Double Suture Anchoring between the Posterior Wall of the Esophagus and the Anterior Wall of the Stomach (SPADE Operation): A Case Series

Simple Summary

SPADE is a novel reconstruction technique that is performed after laparoscopic proximal gastrectomy to reduce reflux. The aim of this study was to demonstrate the clinical outcomes of SPADE operations. Only one patient (2.9%) had reflux symptoms, which required anti-reflux drugs and reflux esophagitis on postoperative endoscopy. No anastomotic leakage was observed after the SPADE method. The rate of strictures at the site of anastomosis was 14.7%, and these patients were well managed with endoscopic ballooning. Therefore, the SPADE operation is a promising reconstruction method after proximal gastrectomy.

Abstract

We introduced SPADE operation, a novel anastomotic method after laparoscopic proximal gastrectomy (PG). Technical modifications were performed and settled. This report aimed to demonstrate the short-term clinical outcomes after settlement. Data from 34 consecutive patients who underwent laparoscopic PG with SPADE between June 2017 and March 2020 were retrospectively reviewed. Reflux was evaluated based on the patients’ symptoms and follow-up endoscopy using Los Angeles (LA) classification and RGB Classification (Residue, Gastritis, Bile). Other complications were classified using the Clavien–Dindo method. The incidence of reflux esophagitis was 2.9% (1/34). Bile reflux was observed in six patients (17.6%), and residual food was observed in 16 patients (47.1%) in the endoscopy. Twenty-eight patients had no reflux symptoms (82.4%), while five patients (14.7%) and one patient (2.9%) had mild and moderate reflux symptoms, respectively. The rates of anastomotic stricture and ileus were 14.7% (5/34) and 11.8% (4/34), respectively. No anastomotic leakage was observed. The incidence of major complications (Clavien-Dindo grade III or higher) was 14.7%. The SPADE operation following laparoscopic PG is effective in reducing gastroesophageal reflux. Its clinical usefulness should be validated using prospective clinical trials.

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.

Function-Preserving Gastrectomy for Early Gastric Cancer

Simple Summary

For patients with early gastric cancer (EGC), a good prognosis is achieved by conventional standard gastrectomy with radical lymphadenectomy. However, postgastrectomy syndrome is often inevitable and results in decreased quality of life (QOL). To improve patients’ QOL, proximal gastrectomy instead of total gastrectomy and pylorus-preserving gastrectomy instead of distal gastrectomy have been widely accepted as function-preserving gastrectomies. Recently, personalized, minimized gastrectomy with sentinel node navigation surgery has been developed and is expected to be an ideal treatment option for patients with EGC. Herein, we review the indications, surgical techniques, and postoperative outcomes of function-preserving gastrectomy.

Abstract

Recently, minimally invasive (endoscopic or laparoscopic) treatment for early gastric cancer (EGC) has been widely accepted. However, a standard gastrectomy with radical lymphadenectomy is generally performed in patients with EGC who have no indications for endoscopic resection, and postgastrectomy dysfunction is one of the problems of standard gastrectomy. Function-preserving gastrectomy, such as proximal gastrectomy and pylorus-preserving gastrectomy, can be considered when attempting to preserve the patient’s quality of life (QOL) postoperatively. In addition, sentinel node navigation surgery for EGC has been applied in clinical practice in several prospective studies on function-preserving personalized minimized gastrectomy. In the near future, the sentinel lymph node concept is expected to form the basis for establishing an ideal, personalized, minimally invasive function-preserving treatment for patients with EGC, which will improve their postoperative QOL without compromising their long-term survival. In this review article, we summarize the current status, surgical techniques, and postoperative outcomes of function-preserving gastrectomy for EGC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

The evaluation of the postoperative quality of life in patients undergoing radical gastrectomy for esophagogastric junction cancer using the Postgastrectomy Syndrome Assessment Scale-45: a nationwide multi-institutional study

PURPOSE

This retrospective nationwide survey investigated the quality of life (QOL) of patients with esophagogastric junction cancer after gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45.

METHODS

The Postgastrectomy Syndrome Assessment Scale-45 comprises 45 questions classified into symptoms, living status, and QOL domains. A total of 1950 gastrectomized patients with upper-third gastric or esophagogastric junction cancer returned the completed forms. Among them, 224 eligible patients with esophagogastric junction cancer were selected, including 86, 120, and 18 patients who underwent total gastrectomy, proximal gastrectomy (reconstruction-esophagogastrostomy: 56; double-tract method: 51), and other procedures, respectively.

RESULTS

The postoperative period was significantly shorter (47 ± 30 vs. 34 ± 30 months, p = 0.002), and the rates of early-stage disease and minimally invasive approaches significantly higher (both p < 0.001) in the proximal gastrectomy group than in the total gastrectomy group. Despite advantageous background factors for proximal gastrectomy, the postoperative QOL did not differ markedly between the groups. Compared to patients who underwent reconstruction with the double-tract method, patients who underwent esophagogastrostomy had significantly larger remnant stomachs but a similar QOL.

CONCLUSION

Even with total gastrectomy, a postoperative QOL comparable to that with proximal gastrectomy can be maintained. Clarifying the optimal reconstruction methods for proximal gastrectomy for esophagogastric junction cancer is warranted.

TRIAL REGISTRATION

This study was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Robot-assisted Valvuloplastic Esophagogastrostomy by Double-flap Technique Using a Knifeless Linear Stapler After Proximal Gastrectomy

After proximal gastrectomy, valvuloplastic esophagogastrostomy by double-flap technique could be the ideal reconstruction to prevent gastroesophageal reflux. However, it is demanding procedure in laparoscopic surgery. In this video, we demonstrate a robot-assisted double-flap technique using a knifeless stapler.

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.

Robotic-assisted proximal gastrectomy using the double-flap technique for early gastric cancer with situs inversus totalis: a case report

Background

The robotic system has been applied in the treatment of gastric cancer (GC), and the procedure has been found to be safe and feasible. Situs inversus totalis (SIT) is a relatively rare autosomal recessive congenital anomaly. We successfully performed robot-assisted proximal gastrectomy (RAPG) and handsewn double-flap esophagogastrostomy for GC in a patient with SIT.

Case presentation

A 71-year-old woman was referred to us with an asymptomatic ulcerative lesion in the upper body of the stomach. Computed tomography revealed that she had SIT. She was diagnosed with cT1bN0M0, cStageIA gastric cancer. RAPG with lymph node dissection and handsewn double-flap esophagogastrostomy was performed. Robotic surgery enabled the surgeon to perform the surgery without changing his position and experiencing any confusion resulting from the patient’s reversed anatomy. It took 448 min, and no intraoperative complications occurred. Her postoperative course was uneventful; she was discharged on postoperative day 10. The final pathologic report showed pT1b1N0M0, pStage IA.

Conclusions

This is the first case describing RAPG with handsewn double-flap esophagogastrostomy for a SIT patient with early GC.

Robotic Proximal Gastrectomy with Double-Tract Reconstruction for Gastroesophageal Junction Cancer

The current standard surgical procedure for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal involvement is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to decreased levels of ghrelin (a "hunger hormone" secreted by the stomach) and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) with an anti-reflux technique such as double-tract reconstruction (DTR) can improve quality of life (QoL) by preserving gastric function.1 A recent Japanese prospective GEJ adenocarcinoma study reported a low incidence of lymph node metastases at peripyloric stations,2 indicating the oncological safety of PG for GEJ adenocarcinoma regardless of tumor stage. As a result, PG is increasingly performed in South Korea and Japan, although the QoL benefit of PG over TG remains unknown.3, 4 We have performed PG with DTR in select cases with satisfying short-term outcomes. In this video, we introduce our technique for robotic PG with DTR. The presented case is a 75-year-old woman with GEJ adenocarcinoma that showed an excellent response to preoperative chemoradiation therapy. The patient underwent robotic PG with DTR. Fluorescent sentinel lymphatic mapping was performed by injecting indocyanine green solution (total of 2 ml, at four quadrants around the tumor at submucosal space) via endoscopy at the beginning of the operation. It showed absence of sentinel lymphatic flow to peripyloric lymph nodes, which were thus considered safe to preserve. Pathologic examination confirmed a complete response. The patient's recovery was favorable, and she reported satisfaction with her QoL and good appetite, though some intermittent bloating after eating. PG with DTR has theoretical disadvantages including incomplete lymph node removal, which may result in recurrence; therefore, PG should be carefully performed for P/GEJ cancers with low risk of perigastric lymph node metastases, such as cT1 tumors or GEJ tumors with limited gastric involvement.2 In addition, delayed gastric emptying of the remnant stomach can cause upper gastrointestinal symptoms such as reflux and bloating. The QoL benefits of PG with DTR must be demonstrated before encouraging its use in the USA and other countries. International collaboration is warranted to test the benefits and safety of PG, and the effective use of sentinel lymphatic mapping, to standardize the surgical care of patients with P/GEJ cancers.

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.

Clinical outcomes of proximal gastrectomy for gastric cancer: A comparison between the double-flap technique and jejunal interposition

Background

The optimal reconstruction method after proximal gastrectomy (PG) has been debatable. Recent reports have shown that the double-flap technique (DFT) provides good outcomes in terms of postoperative nutritional status and quality of life. However, no study has compared the clinical outcomes of the DFT with other reconstruction methods. Here, we evaluated and compared the clinical outcomes between the DFT and jejunal interposition (JI) after PG for gastric cancer.

Materials and methods

The medical records of 34 consecutive patients who had undergone PG for upper third gastric cancer between January 2011 and October 2016 were reviewed retrospectively. The main factors investigated were surgical outcomes, postoperative nutritional status, symptoms, and endoscopic findings 1 year after surgery.

Results

Thirty-four patients were enrolled (DFT, 14; JI, 20). The operation time was similar between the two techniques (228 and 246 minutes for DFT and JI, respectively, P = 0.377), as were the rates of anastomotic complications (7% and 0% for DFT and JI, respectively, P = 0.412). Body weight loss was significantly lower in the DFT group than in the JI group (-8.1% vs -16.1%, P = 0.001). Total protein and albumin levels were higher in the DFT group than in the JI group (0% vs -2.9%, P = 0.053, and -0.3% vs -6.1%, P = 0.077, respectively). One patient in the DFT group and no patients in the JI group experienced reflux esophagitis (≥ grade B) (P = 0.393). Anastomotic strictures were not observed as postoperative complications in either group.

Conclusions

Surgical outcomes revealed that the DFT was safe and feasible, similar to JI. In terms of controlling postoperative body weight loss, the DFT is a better reconstruction technique than JI after PG.

Feasibility and quality of life assessment of laparoscopic proximal gastrectomy using double-tract reconstruction

PURPOSE

As the frequency of cancer in the proximal stomach or around the esophagogastric junction (EGJ) increases worldwide, the use of laparoscopic proximal gastrectomy (LPG) has expanded. This study evaluated the safety of LPG with double-tract reconstruction (LPG-DT) and the resulting quality of life (QOL) of patients.

METHODS

In this retrospective cohort study, we reviewed the data of patients who underwent LPG-DT via linear-stapled esophagojejunostomy for gastric or EGJ cancer between 2013 and 2019, and outcomes were compared with those of laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG-RY) peMME000372rformed over the same period. Surgical outcomes, changes of nutritional parameters, and chronological QOL as evaluated using the Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire were compared in the propensity-matched cohorts.

RESULTS

In total, 289 patients (99 LPG-DT and 190 LTG-RY) were eligible and the outcomes were evaluated in the propensity-matched cohorts (n = 75 each). Operative time and the incidence of complications (≥ grade III) were comparable. Reflux esophagitis was more frequent in the LPG-DT group (8.0% vs. 0%), whereas the incidence of anastomotic stricture did not differ. The percentage rates of body weight loss and hemoglobin reduction were lower in the LPG-DT group at any time point within postoperative 2 years but show no statistical differences. In PGSAS-37 (n = 26, n = 23), the diarrhea and quality of ingestion scores were slightly better in the LPG-DT group.

CONCLUSIONS

The present study suggested that our LPG-DT is feasible and safe in appropriately selected patients, and it may provide slightly better outcomes in nutrition and QOL compared with LTG-RY.

A Novel Valvuloplastic Esophagogastrostomy Technique for Laparoscopic Transhiatal Lower Esophagectomy and Proximal Gastrectomy for Siewert Type II Esophagogastric Junction Carcinoma-the Tri Double-Flap Hybrid Method

We developed a novel technique for valvuloplastic esophagogastrostomy, named tri double-flap hybrid method (TDF). TDF is shown to be simple and useful for Siewert type II esophagogastric junction carcinoma.

BACKGROUND

Research has found valvuloplastic esophagogastrostomy using the conventional hand-sutured double-flap (CDF) technique to be a useful anti-reflux procedure after proximal gastrectomy. However, no study has focused on this reconstruction procedure after laparoscopic transhiatal lower esophagectomy and proximal gastrectomy (LEPG) for esophagogastric junction carcinoma primarily because of its profound difficulty. Thus, we devised a novel technique for valvuloplastic esophagogastrostomy comprising triangular linear-stapled esophagogastrostomy and hand-sutured flap closure, which we term the tri double-flap hybrid (TDF) method.

METHODS

After reviewing our institution's prospective gastric cancer database, 59 consecutive patients with Siewert type II esophagogastric junction carcinoma who underwent LEPG with valvuloplastic esophagogastrostomy from January 2014 to August 2018 were analyzed. Short- and mid-term surgical outcomes were then compared between the LEPG-TDF and LEPG-CDF groups to evaluate the efficacy of the TDF method.

RESULTS

The median operative time was 316 min (184-613 min) and blood loss was 22.5 ml (0-180 ml). In comparison between the two groups, the LEPG-TDF group had a significantly shorter operative time (298 vs. 336 min, p = 0.041) and significantly lower postoperative anastomotic leak/stenosis rates (0 vs. 14.2%, p = 0.045), compared to the LEPG-CDF group. No patient suffered from severe gastroesophageal reflux symptoms (Visick score ≥ III).

CONCLUSIONS

This study showed that double-flap valvuloplastic esophagogastrostomy is safe and feasible for reconstruction after LEPG for Siewert type II esophagogastric junction carcinoma. Moreover, the TDF method is a simple and useful technique that offers a shorter operative time and lower morbidity compared to the CDF technique.

Short-term and long-term comparisons of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy by the double-flap technique and laparoscopy-assisted total gastrectomy for proximal gastric cancer

BACKGROUND

Although proximal gastrectomy (PG) is a recognized surgical procedure for early proximal gastric cancer, total gastrectomy (TG) is sometimes selected due to concern about severe gastroesophageal reflux. Esophagogastrostomy by the double-flap technique (DFT) is an anti-reflux reconstruction after PG, and its short-term effectiveness has been reported. However, little is known about the long-term effects on nutritional status and quality of life (QOL).

METHODS

Gastric cancer patients who underwent laparoscopy-assisted PG (LAPG) with DFT or laparoscopy-assisted TG (LATG) between April 2011 and March 2014 were retrospectively analyzed. Body weight (BW), body mass index (BMI), and prognostic nutritional index (PNI) were reviewed to assess nutritional status, and the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 was used to assess QOL.

RESULTS

A total of 36 patients (LATG: 17, LAPG: 19) were enrolled. Four of 17 LATG patients (24%) were diagnosed with Stage ≥II after surgery, and half received S-1 adjuvant chemotherapy. BW and PNI were better maintained in LAPG than in LATG patients until 1-year follow-up. Seven of 16 LATG patients (44%) were categorized as "underweight (BMI<18.5 kg/m2)" at 1-year follow-up, compared to three of 18 LAPG patients (17%; p = 0.0836). The PGSAS-45 showed no significant difference in all QOL categories except for decreased BW (p = 0.0132). Multivariate analysis showed that LATG was the only potential risk factor for severe BW loss (odds ratio: 3.03, p = 0.0722).

CONCLUSIONS

LAPG with DFT was superior to LATG in postoperative nutritional maintenance, and can be the first option for early proximal gastric cancer.

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.

Functional and nutritional outcomes after gastric cancer surgery

Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.