Functional Advantages of Proximal Gastrectomy with Jejunal Interposition Over Total Gastrectomy with Roux-en-Y Esophagojejunostomy for Early Gastric Cancer

Efficacy of robot-assisted double-flap techniques with refinements to minimize anastomosis-related complications after proximal gastrectomy

PURPOSE

The double-flap technique (DFT) is an anti-reflux reconstruction procedure performed after proximal gastrectomy (PG), but its complexity and high incidence of anastomotic stenosis are problematic. We conducted this study to demonstrate the efficacy of robot-assisted DFT, with refinements, to address these issues.

METHODS

Surgical outcomes were compared between the following procedures modified over time at our institution: conventional open DFT (group O, n = 16); early robotic DFT (group RE, n = 19), which follows the conventional open PG approach; and late robotic DFT (group RL, n = 21), which incorporates refinements to the early robotic DFT technique by exploiting more of the robotic capabilities available. These robotic capabilities include pre-anchoring the stomach to the diaphragmatic crus and connecting it to the esophagus, placing interrupted sutures for anastomosis, and maximally embedding the esophagus through the entire flap.

RESULTS

Anastomotic stenosis requiring balloon dilatation developed in two (11.8%) patients from group O and three (14.3%) from group RE, but not in any patients from group RL. Reflux esophagitis, classified as Los Angeles Classification grade ≥ B, decreased from 25.0% in group O to 10.5% in group RE and was completely controlled in group RL (group RL vs group O, odds ratio 0.065, 95% confidence interval < 0.001-0.684, P = 0.007).

CONCLUSION

Robotic surgery helps minimize anastomotic stenosis, while enhancing the benefits of anti-reflux reconstruction with DFT.

The comparison of post-proximal gastrectomy digestive tract reconstruction methods

OBJECTIVE

Proximal gastrectomy (PG) is commonly used to remove proximal gastric cancer leading to gastroesophageal reflux and requires digestive tract reconstruction. This study is to compare the performance of esophagogastrostomy (EG), jejunal interposition (JI), and double tract reconstruction (DTR) on post-PG reconstruction effectiveness.

METHODS

A retrospective study was conducted using the clinical data of 94 PG patients who underwent digestive tract reconstruction by EG (37 patients), JI (29 patients) or DTR (28 patients). The safety of the reconstruction procedure and the incidence of surgical complications were evaluated using the Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Questionnaire (GERD-Q) scale score, gastroscopy, barium meal examination of digestive tract, and 24-h pH monitoring.

RESULTS

The DTR group showed significantly lower GERD-Q scores (p < 0.05) and RSI scores (p < 0.05) compared to the EG and JI groups. This indicates that DTR is more effective in preventing reflux esophagitis. The pre- and post-surgical GERD-Q scores assessed by esophageal 24-h pH acidity measurements and Los Angeles Grading were reduced in all patient groups, with the DTR group showing better results than the other two (p < 0.05). The results of the EORTC QLQ-STO22 questionnaire indicated that the DTR group had a higher overall health status score than the other two groups (p < 0.001).

CONCLUSION

EG had a short surgical duration and less bleeding. JI reduced the prevalence of reflux esophagitis. DTR presented improved prevention of reflux esophagitis and enhanced quality of life.

The Safety and Anti-Reflex Effect of Robotic Double-Tract Reconstruction After Proximal Gastrectomy for Gastric Cancer

PURPOSE

Double-tract reconstruction (DTR) is one of the major procedures following proximal gastrectomy (PG) with anti-reflex function for the esophagus. Although many studies demonstrated the feasibility of laparoscopic DTR, there is a lack of research on robotic DTR. We aimed to assess the safety and feasibility of robotic DTR following PG.

METHODS

Esophagojejunostomy was performed with a robotic stapler under endoscopic observation using the TilePro function of the Davinci Xi surgical system. The gastrojejunostomy procedure slightly differed depending on the size of the remnant stomach. Along with short-term surgical outcomes, long-term outcomes were compared based on the size of the remnant stomach.

RESULT

Thirty patients underwent robotic DTR. The median value of operative bleeding was 10 mL, although the median operative and reconstruction times were 398 and 119 min, respectively. Anastomotic complications were absent, and reflux esophagitis was not observed endoscopically 1 year after operation. Body weight loss, symptoms, and blood test findings did not differ significantly.

CONCLUSION

Robotic DTR may be a safe and favorable procedure in terms of the postoperative course and incidence of reflux esophagitis.

Useful of proximal gastrectomy with double-tract reconstruction in preventing glucose spikes

BACKGROUND

Volatile glucose levels after gastrectomy induce dumping syndrome, which adversely affects patient quality of life. This study aimed to evaluate the glycemic variability of proximal gastrectomy with double-tract reconstruction (PGDTR) as a function-preserving procedure.

METHODS

This study used a continuous glucose monitoring (CGM) system to record glycemic profiles of patients who underwent PGDTR or total gastrectomy (TG) and compared them. Moreover, this study evaluated postgastrectomy syndrome, including dumping symptoms, between the PGDTR and TG groups using the 37-item Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire.

RESULTS

Of note, 44 patients underwent PGDTR, and 42 patients underwent TG, which included more advanced cases. CGM results showed that the SD, relative SD, and maximum drop in glucose level between 30 min and 2 h after a meal were smaller in the PGDTR group than in the TG group (14.81 vs 22.40 mg/dL [P < .001], 0.14 vs 0.20 mg/dL [P < .001], and 42.06 vs 117.67 mg/dL [P < .001], respectively). For nocturnal glucose levels, SD and percentage time below the range were smaller in the PGDTR group than in the TG group (11.76 vs 15.16 mg/dL [P = .005] and 11.25% vs 35.27% [P < .001]). The PGDTR group generally performed better than the TG group on all the PGSAS-37 questionnaire items. Patients in the PGDTR group without food inflow into the remnant stomach showed similar CGM results as those in the TG group but with stronger dumping symptoms.

CONCLUSION

Food inflow into the remnant stomach is essential for PGDTR to be a function-preserving procedure as it leads to the control of dumping symptoms and lower glucose level spikes.

Surgical outcomes of laparoscopic proximal gastrectomy for upper-third gastric cancer: esophagogastrostomy, gastric tube reconstruction, and double-tract reconstruction

BACKGROUND

There is no consensus on the optimal reconstruction technique after proximal gastrectomy. The purpose of this study was to retrospectively compare the surgical outcomes among esophagogastrostomy (EG) anastomosis, gastric tube (GT) reconstruction and double-tract (DT) reconstruction in patients who underwent laparoscopic proximal gastrectomy (LPG) to clarify the superior reconstruction method.

METHODS

This study enrolled 164 patients who underwent LPG at the Northern Jiangsu People's Hospital in Jiangsu between January 2017 to January 2022 (EG: 51 patients; GT: 77 patients; DT: 36 patients). We compared the clinical and pathological characteristics, surgical features, postoperative complications, nutritional status, and quality of life (QOL) among the above three groups.

RESULTS

Mean operative time was longer with the DT group than the remaining two groups (p = 0.001). With regard to postoperative complications, considerable differences in the postoperative reflux symptoms (p = 0.042) and reflux esophagitis (p = 0.040) among the three groups were found. For the nutritional status, total protein, hemoglobin and albumin reduction rates in the GT group were significantly higher than the other two groups at 12 months postoperatively. In the PGSAS-45, three assessment items were better in the DT group significantly compared with the esophageal reflux subscale (p = 0.047, Cohen's d = 0.44), dissatisfaction at the meal (p = 0.009, Cohen's d = 0.58), and dissatisfaction for daily life subscale (p = 0.012, Cohen's d = 0.56).

CONCLUSIONS

DT after LPG is a valuable reconstruction technique with satisfactory surgical outcomes, especially regarding reduced reflux symptoms, improving the postoperative nutritional status and QOL.

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.

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.

Extent of gastrectomy and lymphadenectomy for gastric adenocarcinoma

Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well-established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This chapter outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed.

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.

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

IMPORTANCE

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

OBJECTIVES

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

Total gastrectomy and LN dissection.

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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.

Simultaneous determination of 11 illicit drugs and metabolites in wastewater by UPLC-MS/MS

Assessing collective drug consumption based on the concentrations of illicit drugs and their metabolites in wastewater is a new technology. Currently, this technology is receiving attention in China, and methods for multiple illicit drug detection in wastewater are urgently needed. In our study, a method with a short runtime (7 min), a small solid-phase extraction (SPE) loading volume (50 mL) and high sensitivity (lower limits of quantitation (LLOQs) ranged from 0.2 to 5 ng/L) was developed for the simultaneous determination of amphetamines, ketamine, opiates, cocaine and their metabolites in wastewater. Samples were enriched by SPE on a mixed-mode sorbent (Oasis MCX) and analyzed by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The limits of detection (LODs) ranged from 0.1 to 2 ng/L, and the LLOQs varied between 0.2 and 5 ng/L. Moreover, the method developed was applied to real wastewater samples collected from 15 different wastewater treatment plants (WWTPs). In the results, the most abundant compounds were morphine (1.8-46.6 ng/L) and codeine (3.7-24.9 ng/L), which were detected in 13 WWTPs. After successful optimization of the UPLC-MS/MS conditions and sample loading pH, the method developed is able to meet the needs of common illicit drug monitoring and high-throughput analysis requirements.

Semi-embedded valve anastomosis a new anti-reflux anastomotic method after proximal gastrectomy for adenocarcinoma of the oesophagogastric junction

Background

There is a high probability of gastroesophageal reflux after laparoscopic proximal gastrectomy for adenocarcinoma of the oesophagogastric junction (AEG). Various anti-reflux anastomotic methods are emerging in clinical practice; however, none of them have been widely accepted. We have innovated a new type of anti-reflux anastomotic method, named semi-embedded valve anastomosis. The aim of this study was to explore the feasibility and anti-reflux effect of the new anastomotic method.

Methods

The clinical data of 28 patients with Siewert II AEG who were treated by semi-embedded valve anastomosis were collected. The key point of the operation is to reconstruct a simulated valve and form an anti-reflux barrier similar to the physiological mechanism. The gastroesophageal reflux disease questionnaire (GerdQ) and classification of gastroesophageal reflux under electron microscopy were used to evaluate gastroesophageal reflux after the operation.

Results

The mean operative duration was 164.3 ± 19.0 min, the median intraoperative haemorrhage volume was 65 ml, the average number of lymph nodes dissected was 23 ± 2.6, the time for valve construction was 15.8 ± 3.2 min, the time for anastomotic reconstruction was 35.4 ± 4.8 min, the median time to first flatus was 3 d, and the median hospitalization duration was 12 d. There was one case of postoperative anastomotic stenosis. The GerdQ score [median (range)] was as follows: 2 (0–6), preoperation; 0 (0–8), 1 month postoperation; 2 (0–12), 3 months postoperation; and 3 (0–12), 6 months postoperation. The Wilcoxon signed-rank sum test was carried out at different times after the operation and the day before the operation, and the differences were not significant. There was one case of grade B gastroesophageal reflux according to the Los Angeles classification system among the gastrofibroscopic re-examination reports of 28 cases.

Conclusion

Semi-embedded valve anastomosis is safe and feasible after proximal gastrectomy for Siewert II AEG and has good anti-reflux effects.

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.

Advantages of Distal Subtotal Gastrectomy over Total Gastrectomy in the Quality of Life of Long-Term Gastric Cancer Survivors

Purpose

This study evaluated differences and shifting patterns in the health-related quality of life (HRQoL) of 5-year gastric cancer survivors after either a distal subtotal gastrectomy (DSG) or total gastrectomy (TG).

Materials and Methods

We analyzed the prospectively collected HRQoL data of 528 patients who survived 5 years without recurrence using the European Organization for the Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC Quality of Life Questionnaire-Stomach module according to the type of surgery. The purpose was to identify the proportion of patients with deteriorating HRQoL and to assess the clinical significance of these changes.

Results

Deteriorating HRQoL was prevalent in both groups, including a large proportion of the DSG group. Decreased overall health status and scores on several function scales were less in the DSG group, while increases on the symptom scales were higher in the TG group. For most of the scales, gaps in HRQoL during the early postoperative period did not merge within the 5 years. Scores on the diarrhea and body image scales revealed "moderate changes" in both groups.

Conclusions

During the 5-year period after surgery, the TG group suffered from inferior HRQoL compared to the DSG group. However, a large proportion of the DSG group also suffered HRQoL deterioration. In general, the TG group experienced more HRQoL decline, with diarrhea and body image being the major concerns for both groups. To improve HRQoL after gastrectomy, patients must be better informed about post-gastrectomy symptoms. These symptoms must be vigorously investigated, and medical interventions should be available parallel to nutritional support. Favorable evidence of function-preserving gastrectomy should be established and disseminated to improve the HRQoL of early gastric cancer patients.

Reconstruction Methods and Complications of Esophagogastrostomy and Jejunal Interposition in Proximal Gastrectomy for Gastric Cancer: A Meta-Analysis

BACKGROUND

Proximal gastrectomy is used for the treatment of primary gastric cancer by open or laparoscopic surgery in the upper third of the stomach. Esophagogastrostomy (EG) or jejunal interposition (JI) is widely used in various reconstruction methods after proximal gastrectomy. We conducted a meta-analysis of EG and JI for treatment of gastric cancer.

MATERIALS AND METHODS

A search of PubMed, Embase, MEDLINE, J-STAGE, and Cochrane Library identified retrospective series on EG and JI. Weight mean differences (WMDs), odds ratios (ORs), and 95% confidence intervals (CIs) were used to analyze the operation-related data and postoperative complications. Heterogeneity was evaluated by the I 2 test, and potential publication bias was assessed with Egger regression tests and sensitivity analysis.

RESULTS

Eight studies were selected, and 496 patients were included. EG group benefits were 44.81 min shorter operating time (P < 0.001), 56.58 mL less blood loss (P = 0.03), and 7.4 days shorter hospital stay time (P < 0.001) than the JI group. Between the two groups, there was no significant difference in anastomotic leakage; otherwise, the EG group had a lower risk of anastomotic stenosis (OR = 0.44, 95%CI = 0.20 to 0.97, P = 0.04), lower risk of intestinal obstruction (OR = 0.07, 95%CI = 0.01 to 0.43, P = 0.004), and higher risk of reflux esophagitis (OR = 2.47, 95%CI = 1.07 to 5.72, P = 0.03).

CONCLUSION

The results of our study indicated that EG has significant advantages during the perioperative period and in short-term outcomes compared to JI.

Surgical choice of proximal gastric cancer in China: a retrospective study of a 30-year experience from a single center in China

Background: Total gastrectomy with D2 lymphadenectomy is indicated for proximal advanced gastric cancer located in the upper one-third of the stomach; however, due to preserved function and clinical benefits of a proximal gastrectomy, the choice of a surgical method for patients with proximal early-stage gastric cancer remains controversial.Methods: We conducted a retrospective study involving 649 patients with proximal gastric cancer. The clinical-pathological features, characteristics, lymph node metastatic patterns, prognosis, postoperative complications, and recurrence were compared between the patients who underwent proximal and total gastrectomies with different T and N stages.Results: The lymph node metastatic rates among T stages were significantly different. There was no difference in overall survival rates for stage Ia, Ib, and IIa patients but significant difference in T3 and T4 stages who underwent proximal and total gastrectomy. Complications were more frequently detected in patients who underwent total gastrectomy than proximal gastrectomy.Conclusion: Considering the survival benefits and preserved function, proximal gastrectomy can be performed safely in stage Ia and Ib gastric cancer (T1N0, T1N1, and T2N0) with an excellent remission rate. Proximal gastrectomy is not recommended for advanced gastric cancer.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients (KSES002)

AIM

The present study aimed to evaluate the efficacy of short-term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6-8 weeks in the early post-gastrectomy period on postoperative long-term body weight loss (BWL).

METHODS

We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post-gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6-8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition-related blood parameters.

RESULTS

Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77-12.54] vs 15.11 ± 6.78% [95% CI: 11.63-18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21-8.41] vs 5.96 ± 6.20% [95% CI: 3.72-8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG.

CONCLUSIONS

Daily nutritional intervention (300 kcal/day ED) for 6-8 weeks reduced %BWL not only at postoperative 6-8 weeks but also at 1 year in patients who underwent TG.

Surgical resection of gastric stump cancer following proximal gastrectomy for adenocarcinoma of the esophagogastric junction

BACKGROUND

Proximal gastrectomy (PG) is performed widely as a function-preserving operation for early gastric cancer located in the upper third of the stomach and is an important function-preserving approach for esophagogastric junction (EGJ) adenocarcinoma. The incidence of gastric stump cancer (GSC) after PG is increasing. However, little is known about the GSC following PG because very few studies have been conducted on the disease.

AIM

To clarify clinicopathologic features, perioperative complications, and long-term survival rates after the resection of GSC following PG.

METHODS

Data for patients with GSC following PG for adenocarcinoma of the EGJ diagnosed between January 1998 and December 2016 were retrospectively reviewed. Multivariate analysis was performed to identify factors associated with overall survival (OS). GSC was defined in accordance with the Japanese Gastric Cancer Association.

RESULTS

A total of 35 patients were identified. The median interval between the initial PG and resection of GSC was 4.9 (range 0.7-12) years. In 21 of the 35 patients, the tumor was located in a nonanastomotic site of the gastric stump. Total gastrectomy was performed in 27 patients; the other 8 underwent partial gastrectomy. Postoperative complications occurred in 6 patients (17.1%). The tumor stage according to the depth of tumor invasion was T1 in 6 patients, T2 in 3 patients, T3 in 9 patients, and T4 in 17 patients. Lymph node metastasis was observed in 18 patients. Calculated 1-, 3-, and 5-year OS rates were 86.5%, 62.3%, and 54.2%, respectively. Multivariate analysis showed advanced T stage to be associated with OS.

CONCLUSION

This study reveals the characteristics of GSC following PG for adenocarcinoma of the EGJ and suggests that a surgical approach can lead to a satisfactory outcome.

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.

Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study

INTRODUCTION

Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety.

METHODS

This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition.

RESULTS

The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group.

CONCLUSION

Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.

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.

Short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy with a very small remnant stomach for cStage I proximal gastric carcinoma

BACKGROUND

Total or proximal gastrectomy is usually performed for early proximal gastric carcinoma, but the optimal type of gastrectomy is still unknown. We evaluated short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy (LsTG) in comparison with laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG).

METHODS

We analyzed 113 patients who underwent LsTG (n = 38), LTG (n = 48), or LPG (n = 27) for cStage I gastric cancer located in the upper third of the stomach. Postoperative morbidities, nutritional status including body weight, serum albumin, hemoglobin, the prognostic nutritional index (PNI), and endoscopic findings at 1 year after surgery were compared between LsTG and both LTG and LPG.

RESULTS

Operation time and intraoperative blood loss were similar among the three groups. The incidence of postoperative morbidities was lower in LsTG than in LTG. The degree of body weight loss was significantly smaller in LsTG than in LTG at 6 and 12 months. At 12 months, LsTG resulted in better serum albumin and PNI than LPG, and better hemoglobin than LTG. Endoscopic examination demonstrated that one LsTG patient and two LPG patients had reflux esophagitis. Remnant gastritis was observed more frequently in LPG than in LsTG. No LsTG patient had bile reflux, although it was observed in four LPG patients.

CONCLUSIONS

LsTG with a very small remnant stomach had favorable short-term outcomes and nutritional status compared with LTG and LPG, so it may be a better treatment option for cStage I proximal gastric carcinoma.

Laparoscopic proximal gastrectomy with oblique jejunogastrostomy

BACKGROUND

Proximal early gastric cancer is a good indication for totally laparoscopic proximal gastrectomy (TLPG) with double-tract reconstruction (DTR). However, when most of the dietary intake passes through the escape route of the jejunum, the functional benefits of proximal gastrectomy might be similar to those after total gastrectomy. Our DTR procedure was improved for easy passage through the remnant stomach. The purposes of this study were to present a novel technique for intracorporeal DTR using linear staplers after TLPG and to investigate surgical outcomes.

METHODS

DTR was performed using linear staplers only. A side-to-side jejunogastrostomy with twisting of both the remnant stomach and the anal jejunum was performed for the purpose of passing meals through the remnant stomach (an oblique jejunogastrostomy technique). The ten patients who underwent TLPG with DTR from January 2011 to August 2016 in Hokkaido University Hospital were retrospectively reviewed. Their clinicopathological characteristics and surgical and postoperative outcomes were collected and analyzed.

RESULTS

The median duration of operation was 285 (range 146-440) min. No patients required blood transfusions. The number of dissected lymph nodes was 32 (range 22-56). There were no intraoperative complications, and no cases were converted to open surgery. All the patients were pT1N0M0 stage IA. No anastomotic leakage or complications were detected. Postoperative gastrography after reconstruction showed that contrast medium flowed mainly to the remnant stomach. The average percentage body weight loss was 14.0 ± 7.1% at 10 months. The average percentage decrease in serum hemoglobin was 5.4 ± 10.4% at 12 months.

CONCLUSIONS

This novel technique for intracorporeal DTR provided a considerable advantage by the passage of dietary intake to the remnant stomach after LPG.