| BackgroundGastric cancer is one of the most common malignant tumors throughout the world,and the incidence of gastric cancer in China is high.Epidemiologic studies show that the incidence of proximal gastric cancer has been increasing in recent years.Though it has been proved that surgery is a primary option for patients with gastric cancer,there are still many controversies about the operation methods of the proximal gastric cancer.The application of proximal gastrectomy(PG)is limited by two main concerns:the first,oncological safety of the PG;the second,the quality of life of patients receiving different alimentary reconstructions after PG.Because of these controversies,PG is only recommended for early proximal gastric cancer according to the current guidelines.Therefore,a large number of patients with proximal gastric cancer have undergone total gastrectomy(TG)in recent years.However,compared with PG,TG has some obvious disadvantages,such as less food reserves,worse long-term nutritional status and higher incidence of anemia.Meanwhile,recent studies have pointed out that complete nodal clearance along the distal portion of the stomach offers only a marginal survival benefit for patients with proximal gastric cancer,and PG is enough to meet the needs of radical operation for most proximal gastric cancer.Some surgeons thus pointed out that TG for proximal gastric cancer is not always necessary.However,even though the oncological safety of PG could be guaranteed,many surgeons would still choose TG for proximal gastric cancer.The clinical importance of undergoing a total gastrectomy is not only related to oncological safety,but also with expected impaired quality of life brought by esophagogastrostomy after PG.Traditional esophagogastrostomy was widely used after PG,and it has been eliminated gradually due to severe reflux esophagitis.To prevent of reflux esophagitis,surgeons have invented various types of post-PG reconstruction methods,but these methods were not widely popularized due to operative complications or unsatisfactory anti-reflux effect.Proximal gastrectomy with double tract reconstruction(PG-DT)is also a operation method to prevent of reflux esophagitis,which was reported publicly in 1988 by the first time.Afterwards,there were some further researches about PG-DT by Japanese and Korean Scholars.Since 2006,our department has been performing PG-DT.Through studies and practice,we find that PG-DT is superior to other methods,because it balances the operation complexity and anti-reflux effect.We think that DT may be one of the ideal reconstruction methods after PG.At present,PG-DT has become a focus of discussion of surgery for gastric cancer again,but researches on PG-DT is quite few at home and abroad.Therefore,more studies and clinical trails are needed to confirm the feasibility,safety and long-term efficacy of PG-DT for proximal gastric cancer.ObjectiveThe purpose of this study is to compare the clinical efficacy of proximal gastrectomy with double tract reconstruction(PG-DT)and total gastrectomy with Roux-en-Y reconstruction(TG-RY)for proximal gastric cancer.MethodsThe retrospective study was conducted.The clinicopathological data of 132 patients with proximal gastric cancer who underwent PG-DT(n=51)or TG-RY(n=81)in the First Affiliated Hospital of Army Medical University between January 2006 and December 2016 were collected.Observation indicators included intraoperative(operation time and blood loss);postoperative(time to flatus,hospital stay,total complications,metastasis of lymph nodes around distal side of stomach from cases undergoing TG-RY),follow-up(long-term hemoglobin level,incidence of anemia,and survival)parameters.All the data were analyzed by SPSS 20.0.Measurement data with normal distribution were represented as?x±s,and comparisons between groups were analyzed using the t test.Measurement data with skewed distribution were represented as M(QR),and comparisons between groups were analyzed using the Mann-Whitney U test.Comparisons of count data were analyzed using ?2test or nonparametric test.Survival analysis were conducted using the Kaplan-Meier method,and Log-rank test was used to compare survival difference between the two groups.Results1.Comparison of the characteristics between PG-DT group and TG-RY group.No statist ically significant differences were found between two groups in the baseline data,including age,gender,BMI,hemoglobin level before operation,postoperative TNM stage,tumor size and histological differentiation between the two groups(P > 0.05).2.Comparison of intra-and post-operative data between PG-DT group and TG-RY group.There were no significant differences between PG-DT and TG-RY in Volume of intraoperative blood loss[200(200)ml vs.200(195)ml,Z=-1.860,P=0.063],time to flatus[(2.7±1.0)days vs.(2.6±1.1)days,t=0.225,P=0.823],duration of postoperative hospital stay [10(3)days vs.10(4)days,Z=-0.449,P=0.654] and postoperative complications[5.9%(3/51)vs.8.6%(7/81),?2=0.081,P=0.775].Compared with the TG-RY,the total operative time of PG-DT was prolonged[294(97)minutes vs.255(71)minutes,Z=-3.148,P=0.002 ].There were 4 cases with metastasis of lymph nodes located around diatal side of stomach in TG-RY group,and the metastasis rates at No.4d?No.5 and No.6 were 2.47%?4.94% and 3.70% respectively.All of these 4 tumors were T4 in depth and were more than 5 cm in diameter.3.Comparison of hemoglobin level and incidence of anemia in first postoperative year between PG-DT group and TG-RY groupThe hemoglobin data of 42 patients with PG-DT and 56 patients with TG-RY were collected 1 year after operation;The incidence of anemia in the PG-DT group was lower than that of TG-RY group[64.2%(27/42)vs.82.1%(46/56),?2=4.072,P=0.045 ],and PG-DT had higher level of hemoglobin than TG-RY [(114.4±16.3)g/L vs.(106.6±15.0)g/L),t=2.435,P=0.017].4.Follow-up and survival situations between PG-DT group and TG-RY group123 cases were followed up for an average time of 26 months.There was no significant differences between PG-DT group and TG-RY group in 1,3,5 years survival rates(?2=0.890,P=0.345).ConclusionCompared with TG-RY,PG-DT has the same safety and feasibility for proximal gastric cancer.Although the operative time of PG-DT group was a little longer than that of TG-RY,PG-DT had advantages in improving the postoperative hemoglobin level,and there were no significant differences of survival rates between the two groups.PG-DT is a proper surgical method for proximal gastric cancer. |
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