The incidence of AEG has gradually increased in the past two decades, and the incidence of early gastric cancer has increased sharply in China as the improvement of health consciousness and promoting the endoscopic techniques in basic hospitals[9–11]. Guidelines are available for common surgical options for Siewert type I and III of AEG according to the consensusfrom the international tumor cooperation group[12, 13]. More recently,Ivor-Lewis esophagectomywith lymph node dissection (mediastinal and partial abdominal lymph nodes)is recommended for the former,in general ,it can be treated with reference to distal esophageal cancer[14]. In the event of latter, the patient should receive a total gastrectomy with D2lymph node dissection. Treatment of Siewert type II traditionally consisted of surgical resection with proximalstomach for early stage smaller- size tumor and total gastrectomy for larger, invasive tumor. However, it is well documented that proximal gastrectomy with remnant stomach-esophageal anastomosis alone usually results in high anastomotic leakage rate due to reflux esophagitis and delayed gastric emptying[15]. Thus, it is extremely important that an appropriate digestive tract reconstruction has been associated with a decrease rate of complications when underwent proximal stomach resection and is therefore reserved for early stage Siewert type II AEG patients who are not candidates for total gastectomy.
The choice of reconstruction manner after gastrectomy involves not only a continuation of the anatomical structure, but is also aimed to preserve the physiological function. The most attractive of the antrum-preserving alternatives is the double tract method,which consists of subtotal gastrectomy,creation ofthe residual stomach and preservation of the duodenal route. This original operation was described by Aikou T in 1988 in order to gain the smooth transfer of larger foods through the duodenal route[16]. In an attempt to improve functional outcomes, some points were made when carrying out the anastomosis between the residual stomach and the jejunum, maintained the physiological pancreaticocibal synchronism. One debated issue is whether DTR should be offered to young patients.Two reasons to avoid these procedure in young patients relate to the high incidence of gastric stump cancer with increasing age and the morbidity of re-operations in these potentially relapse patients.The presence of distant metastatic condition is generally a contraindication to DTR.These unfortunate patients should be managed with total stomach resection with esophago-jejunostomy(RY).
Several prospective studies have compared the surgical outcomes after LPG with DTR and LTG with RY in the treatment of AEG. No difference was found in improving reflux symptom between the two procedures. However, the increasing percentages of the serum albumin, total protein, and hemoglobin levels were significantly higher in patients received DTR[17–19]. Eiji Nomura et al from the Tokai University Hachioji Hospital reported the results of a study evaluating functional outcomes between differ types of reconstruction following LPG and TG. The post-/preoperative body weight ratios were significantly higher in the patients underwent DTR [20] .Takiguchi et al and Nakamura M et al conducteda propensity-score matching analysis and found double tract building was superior to conventional RY reconstruction after LTG in QoL[3]. Others, however, have reported similar results[21, 22]. Since the nutritional status and QoL followed the DTR after LPG is still controversial, fewer literatureto report it in the treatment of AEG, the purpose of this study is to discuss the clinical and postoperative recovery impact of surgicaloption choice.
In this study, after analyzed the postoperative follow-up data, we find BMI of patients who underwent LPG with DTR was higher than that of patients with LTG procedure, the possible reason was that some patients with gastric tumor had complications such as nutritional deficient diseases,many studies have demonstrated that RY reconstructive style had positive effects on weight loss. The LTG procedure cost more time and dissected more lymph node numbers. About 16 months after surgery, one gastric carcinoma recurrence (5%) was found in LPG group, this data is in agreement with those reported in literature concerned .It was noting that the cancerous rate of gastric stump in LTG maybe closely related to pathological grade and regional lymph node metastasis. In addition, this study showed that the proportion of improved nutritional status was significantly higher than that of LTG. Compared with RY reconstruction after LTG, DTR after LPG could guarantee residual stomach. Unlike removed the whole stomach, this method maintains the continuity of the digestive tract, making it time-saving to perform the procedure. Furthermore, it has a dual route for food passage, reducing the incidence of delayed remnant gastric emptying. Compared with LTG,we found no more serious incidence of reflux symptoms related to gastric stump in LPG (Table 4).We suspected that the fewer malnutrition rate especially low risk of vitaminB12 deficiency in LPG group can be associated with the storage function of the remnant stomach.
In our opinion, the stomach has great role in the maintentance of normal nutrition,working primarily to secret intrinsic factor and to store food so that the frequency of reflux symptoms may be limited. Thus, surgical resection of the whole stomach may lead to the loss of vitaminB12 absorption, necessary for normal hemoglobin synthesis, result in pernicious or macrocytic anemia. Patients received total gastrectomy may require monthly administration of vitaminB12(nasal or intramuscular).Another advantage of preserved distal stomach is that it allows the chyme passes through the gastroduodenal channel, promoting the gastrointestinal peptide hormone exposure, avoiding potential body weight loss caused by excessive growth of intestinal bacteria, insufficient secretion of trypsin and poor absorption(Fig. 3). Postoperatively, patients underwent proximal gastrectomy are able to gain weight and return to a much better level of general nutrition. Additionally, residual stomach often means a larger reservoir than intestinal and therefore less risk for gastrointestinal motility disorder complications. In general, the results of surgical resection of proximal stomach depend on the choice of reconstruction manners. In the literature, the outcomes for patients with differ reconstruction after proximal gastrectomy has been variable. Here, we recommended preserve half of the stomach at least during the procedure of DRT after LPG. DRT has dual-output channel, one is the jejunum - remnant stomach - duodenum - jejunum, and the other is the continuity of the jejunum. Each channelcan provide energy and nutritional stores for body use (Fig). Hence, it mayavoid the risk of high intestinal obstructiondue to the recurrence of abdominal lymph node, except for the condition both the channels are packed with tumor compression.In this research, DRT indeed brings some benefits like ideal postoperative food intake, low risk of anemia and better weight maintenance as the preservation of a partial stomach without burdening the risk of anastomotic strictures, reflux, and indigestion.Thus, the double tract technique appears to be a more physiological reconstruction.
Nowadays, because the proved excellent disease free survival rate of early-stage upper gastric cancer patients, increasing emphasis on recovery of psychological and social roles after operation drew our eyes. Increasing attention on quality of life in patients diagnosed with early stage AEG, therefore a careful survey of postoperative daily life situation is necessary.The QLQ-OG25 moduleis widely used in assessment of the quality of life of AEG patients after surgery.Although, several studies have shown the qoL of DTR after LPG was not superior to that of LTG procedure. This little study showed similar results: in term of long-term results, patients underwentDTR after LPGshowed no significantly postoperative recovery expect dietary restrictions, but the mechanism was still unclear.Even though, for early stage upper gastric cancer patients, we conducted that DTR after LPG may be preferred for surgical treatment.
There were certain limitations in our research. Firstly, the short follow up period–just 2 years was a limitation to elucidate the incidence rate of gastric stump carcinoma after PG. Secondly, relatively simple questionnaire was involved in data analysis, there was no doubt some other parameters might also influence the evaluation result. Clearly, unconsolidated recognition in the perceptions of function recovery definition may also lead to an unconscious bias on participantswhile combining data for self-assessment questionnaire form, relying on the individual understanding of these patients. Finally, this study is based on the retrospective analysis which could have resulted in a selection bias. Another potential interference factor is that the surgical procedure is finished in differ medical units, although the surgeons have acquainted anatomical knowledge and perfect technique.