Double-tract reconstruction is superior to esophagogastrostomy in controlling reflux esophagitis and enhancing quality of life after proximal gastrectomy: Results from a prospective randomized controlled clinical trial in China

A 3-Arm case-matched analysis of anti-reflux reconstruction methods after laparoscopic proximal gastrectomy - Single tract jejunal interposition vs double tract reconstruction vs tube-like stomach reconstruction

BACKGROUND

Owing to reportedly superior prognosis, proximal gastrectomy (PG) is expected to be an alternative to total gastrectomy for upper gastric cancer. However, limited data are available regarding the optimal anti-reflux reconstruction method after PG. This study aimed to evaluate the effect of laparoscopic PG with single-tract jejunal interposition (LPG-STJI), double-tract reconstruction (LPG-DTR), and tube-like stomach reconstruction (LPG-TLR) on surgical outcomes in patients with upper-third gastric cancer.

METHODS

Using propensity score-matching (PSM) to adjust for baseline characteristics, a well-balanced cohort was established by matching each patient who underwent LPG-STJI as the study group with one who underwent LPG-DTR or LPG-TLR as the control group at a 1:1 ratio. This study was registered at ClinicalTrials.gov (No. NCT06347757).

RESULTS

PSM yielded 62 matched pairs, with comparable demographic and tumor characteristics. The incidence of reflux esophagitis at one year postoperatively was significantly lower in the LPG-STJI and LPG-DTR groups than in the LPG-TLR group (11.3 % vs 9.7 % vs 24.2 %, P = 0.046), and fewer patients required proton-pump inhibitor administration (62.9 % vs 56.5 % vs 79.0 %, P = 0.024). In terms of nutritional status, the LPG-STJI group showed minimal changes in postoperative body weight and nutrition-related biochemical indices, approaching preoperative levels by the 12-month mark. In addition, the LPG-STJI group demonstrated a more favorable quality of life than the LPG-DTR and LPG-TLR groups, as assessed using the EORTC QLQ-C30 and QLQ-STO22 questionnaires.

CONCLUSION

LPG-STJI may be the preferred option for anti-reflux reconstruction, since it appears to reduce the occurrence of endoscopic reflux esophagitis and improve quality of life without raising surgical complications or compromising nutritional status. Further well-designed prospective studies are warranted to re-evaluate these findings.

Updated Review of Proximal Gastrectomy for Gastric Cancer or Cancer of the Gastroesophageal Junction

Proximal gastrectomy (PG) has reemerged as a viable surgical option for managing proximal gastric cancer and gastroesophageal junction cancer, particularly for early-stage tumors, offering potential advantages over total gastrectomy (TG). This review examines the evolution of PG, emphasizing surgical techniques and outcomes. Although PG was initially abandoned due to postoperative complications such as reflux esophagitis, advances in reconstruction methods, such as the double-flap technique and double-tract reconstruction, have significantly improved patient quality of life and reduced complications. Modern techniques focus on preserving gastric function, enhancing postoperative nutritional status, and minimizing morbidity, especially compared to TG. However, debates persist regarding the optimal extent of lymphadenectomy, oncological safety, and the risk of metachronous gastric cancer after surgery. Various international guidelines support PG for specific cases, particularly where lymph node involvement is limited, and functional preservation is prioritized. Despite promising survival and quality-of-life outcomes, certain risks, such as anastomotic stenosis and metachronous cancer, remain. The role of PG in treating cancer of the gastroesophageal junction continues to be investigated, with ongoing studies further clarifying its effectiveness. The evolving techniques and increased focus on patient-centered outcomes suggest a renewed role of PG in the surgical management of gastric cancer.

Novel reconstruction method using long and narrow gastric tube in laparoscopic proximal gastrectomy for cancer: a retrospective case series study

Background and objectives

To clarify the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with our novel reconstruction methods.

Methods

Novel method is a reconstruction with a long and narrow gastric tube with widening of the proximal side created by linear stapler, and esophagogastrostomy is performed by linear stapler. In conventional method, esophagogastrostomy is performed by a circular stapler. Short- and long-term outcomes of a novel method were compared with those of conventional method.

Results

A total of 44 patients whom LPG was performed were enrolled in this retrospective study. No cases of anastomotic leakage and stenosis were observed in both groups. The cases of postoperative reflux esophagitis (Grade B or higher) at 1 year after operation in the Novel group were less than those in the Conventional group (17% vs. 44%).

Conclusion

LPG with novel reconstruction method can be easily performed, and may be feasible for the treatment of proximal gastric cancer.

[Cancer of the Esophagogastric Junction: Double Tract Reconstruction - Evidence and Technique]

Adenocarcinoma of the esophagogastric junction (AEG) still represent a certain surgical challenge. In contrary to the trend of thoracoabdominal surgery for AEG I and AEG II cancer, the proximal gastrectomy is regaining popularity through new reconstruction methods such as the double tract reconstruction. Proximal gastrectomy followed by double tract reconstruction represents an alternative for the thoracoabdominal approach for suitable AEG II cancer and an alternative to the total gastrectomy for AEG III cancers. Latest studies suggest a functional benefit of proximal gastrectomy and double tract reconstruction in comparison to total gastrectomy. The accurate indication for proximal gastrectomy for locally advanced cancers has to be established in the near future as well as the influence of the size of the remnant stomach on the outcome, as Asian techniques for early lesions sometimes significantly differ from European. The following article reflects the present evidence on proximal gastrectomy and double tract reconstruction as well as technical aspects in the context of cancer of the esophagogastric junction.