Original Contribution
Kurume Medical Journal, 61, 23-29, 2014
Reconstruction Methods and Complications in Proximal Gastrectomy for Gastric Cancer, and a Comparison with Total Gastrectomy TARO ISOBE, KOUSUKE HASHIMOTO, JUNYA KIZAKI, SATORU MATONO, NAOTAKA MURAKAMI, TETSUSHI KINUGASA, KEISHIRO AOYAGI AND YOSHITO AKAGI Department of Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan Received 30 April 2014, accepted 24 Jun 2014 J-STAGE advance publication 25 August 2014
Edited by OSAMU TSURUTA Summary: Proximal gastrectomy (PG) is a widely accepted, efficient treatment for upper-third early gastric cancer. However, it is associated with reduced quality of life (QOL) following surgery, and cancer recurrence in the remaining stomach. Various reconstruction methods have been proposed, but the optimal method has yet to be determined. We investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications in 101 cases of PG, and additionally compared 93 cases of early gastric cancer treated by PG, and 38 cases treated by total gastrectomy (TG). We found that esophagogastrostomy was superior in terms of operation time, intraoperative blood loss, and postoperative hospital stay, while no significant differences were observed in postoperative complications compared with jejunal interposition or jejunal pouch interposition. We found more cases of multiple gastric cancers and advanced-stage cancer in the TG group than in the PG group. The TG group also had a significantly higher proportion of cases with large tumor diameters, low degrees of differentiation, many lymph node metastases, and advanced-stage disease. There were no differences in the recurrence rate or survival rate between the PG and TG groups. The PG group also showed significantly better results in operating time, intraoperative blood loss, and postoperative complications, with a tendency toward shorter hospital stays. In conclusion, PG is a curative but less invasive treatment for upper-third early gastric cancer, and esophagogastrostomy can be considered the most satisfactory reconstruction method following PG. Key words gastric cancer, proximal gastrectomy, reconstruction
INTRODUCTION
As the H. pylori infection rate in Japan has gradually decreased, the number of cancers of the lower stomach has also declined, while cancers of the upper stomach – including the esophagogastric junction – have increased [1,2]. Until the 1980s, the standard surgery for early stage upper-third gastric cancers was total gastrectomy (TG) + D2 lymphadenectomy. However, metastasis to the pyloric lymph nodes is rare, and the surgery was overly invasive in some cases. Recently, advancements in endoscopic diagnostics and examination devices have resulted in an increase in the proportion of early-stage gastric cancers, and proximal gastrectomy (PG) is therefore now a widely accepted
procedure. This method offers the advantage of greater safety, preservation of digestive functions following surgery, while allowing for a complete cure [3,4]. However, PG is associated with reduced QOL after surgery due to issues such as reflux esophagitis, as well as reccurrences of cancer in the remaining stomach. Medical institutions have attempted a variety of reconstruction methods to address these complications, but an optimal method has yet to be determined [4-7]. The current study investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications and complaints in cases of upper third early gastric cancer treated by PG in our department, and additionally conducted a comparison between cases of PG and TG.
Address correspondence to: Taro Isobe, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan. Tel.: +81-942-35-3311(ext.3505), Fax: +81-942-34-0709 E-mail: [email protected]
ISOBE ET AL.
24
MATERIALS AND METHODS A total of 2,698 patients underwent gastric resection for gastric cancer at Kurume University Hospital over a period of 20 years, from 1989 to 2008. The indications for PG at our institution were: tumor located in the upper third of the stomach; depth of invasion within either mucosal or submucosal tissue; tumor size less than 30 mm in diameter; and no evidence of lymph node metastasis, as confirmed by preoperative endoscopy, barium meal study, and computed tomography. In this study, we examined 101 cases of PG performed for cancer of the upper third of the stomach, excluding patients with multiple gastric cancers, multiple primary cancers, and remnant gastric cancer. Additionally, we excluded those patients with advanced cancer who underwent PG without a lymphadenectomy as a palliative surgery for reasons such as bleeding or obstruction with poor general conditions, but who were outside the indication for PG. The following reconstruction methods after PG were performed: Esophagogastrostomy (EG), which involves anastomosis of the esophagus with the anterior wall of the remaining stomach, where as much of the side of the greater curvature of the stomach as possible is preserved during resection (15 cm or more). The remaining upper part of the greater curvature is sutured to the diaphragm and fixed dorsally. In jejunal interposition (JI), a 10 cm diameter ρ-loop is created at the jejunum, an end-to-side esophageal-jejunal anastomosis is created, and an anastomosis is made with the anterior wall of the remaining stomach, with a 5 cm duct. Jejunal pouch interposition (JPI) involves the creation and interpositioning of a 10 cm jejunal pouch. The selection of procedure was not randomized, but was not made according to background factors. We retrospectively examined the clinicopathological characteristics of the early stage gastric cancers, factors related to the surgery, postoperative complaints, recurrence, and prognosis. To examine the postoperative complaints that are common in this type of surgery, we drew information from regular postoperative observations, questionnaires, and yearly postcard surveys. Through these methods, we evaluated the following factors over the first year after surgery: weight loss and the presence of digestive symptoms, such as heartburn, nausea, heaviness after meals, dysphagia, abdominal pain, and diarrhea. Furthermore, a comparison was made between 93 cases that underwent PG (EG: 60 cases, JI: 21 cases, JPI: 12 cases) and 38 contemporaneous cases that underwent TG for histologically diagnosed early upper gastric cancer.
Terminology used is in accordance with the 3rd English edition of the Japanese Classification of Gastric Carcinoma [8]. Statistical analyses were conducted with the Pearson’s chi-squared test. The survival rate was calculated using the Kaplan-Meier method and examined with the generalized Log-rank test. In all cases, p
Kurume Medical Journal, 61, 23-29, 2014
Reconstruction Methods and Complications in Proximal Gastrectomy for Gastric Cancer, and a Comparison with Total Gastrectomy TARO ISOBE, KOUSUKE HASHIMOTO, JUNYA KIZAKI, SATORU MATONO, NAOTAKA MURAKAMI, TETSUSHI KINUGASA, KEISHIRO AOYAGI AND YOSHITO AKAGI Department of Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan Received 30 April 2014, accepted 24 Jun 2014 J-STAGE advance publication 25 August 2014
Edited by OSAMU TSURUTA Summary: Proximal gastrectomy (PG) is a widely accepted, efficient treatment for upper-third early gastric cancer. However, it is associated with reduced quality of life (QOL) following surgery, and cancer recurrence in the remaining stomach. Various reconstruction methods have been proposed, but the optimal method has yet to be determined. We investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications in 101 cases of PG, and additionally compared 93 cases of early gastric cancer treated by PG, and 38 cases treated by total gastrectomy (TG). We found that esophagogastrostomy was superior in terms of operation time, intraoperative blood loss, and postoperative hospital stay, while no significant differences were observed in postoperative complications compared with jejunal interposition or jejunal pouch interposition. We found more cases of multiple gastric cancers and advanced-stage cancer in the TG group than in the PG group. The TG group also had a significantly higher proportion of cases with large tumor diameters, low degrees of differentiation, many lymph node metastases, and advanced-stage disease. There were no differences in the recurrence rate or survival rate between the PG and TG groups. The PG group also showed significantly better results in operating time, intraoperative blood loss, and postoperative complications, with a tendency toward shorter hospital stays. In conclusion, PG is a curative but less invasive treatment for upper-third early gastric cancer, and esophagogastrostomy can be considered the most satisfactory reconstruction method following PG. Key words gastric cancer, proximal gastrectomy, reconstruction
INTRODUCTION
As the H. pylori infection rate in Japan has gradually decreased, the number of cancers of the lower stomach has also declined, while cancers of the upper stomach – including the esophagogastric junction – have increased [1,2]. Until the 1980s, the standard surgery for early stage upper-third gastric cancers was total gastrectomy (TG) + D2 lymphadenectomy. However, metastasis to the pyloric lymph nodes is rare, and the surgery was overly invasive in some cases. Recently, advancements in endoscopic diagnostics and examination devices have resulted in an increase in the proportion of early-stage gastric cancers, and proximal gastrectomy (PG) is therefore now a widely accepted
procedure. This method offers the advantage of greater safety, preservation of digestive functions following surgery, while allowing for a complete cure [3,4]. However, PG is associated with reduced QOL after surgery due to issues such as reflux esophagitis, as well as reccurrences of cancer in the remaining stomach. Medical institutions have attempted a variety of reconstruction methods to address these complications, but an optimal method has yet to be determined [4-7]. The current study investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications and complaints in cases of upper third early gastric cancer treated by PG in our department, and additionally conducted a comparison between cases of PG and TG.
Address correspondence to: Taro Isobe, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan. Tel.: +81-942-35-3311(ext.3505), Fax: +81-942-34-0709 E-mail: [email protected]
ISOBE ET AL.
24
MATERIALS AND METHODS A total of 2,698 patients underwent gastric resection for gastric cancer at Kurume University Hospital over a period of 20 years, from 1989 to 2008. The indications for PG at our institution were: tumor located in the upper third of the stomach; depth of invasion within either mucosal or submucosal tissue; tumor size less than 30 mm in diameter; and no evidence of lymph node metastasis, as confirmed by preoperative endoscopy, barium meal study, and computed tomography. In this study, we examined 101 cases of PG performed for cancer of the upper third of the stomach, excluding patients with multiple gastric cancers, multiple primary cancers, and remnant gastric cancer. Additionally, we excluded those patients with advanced cancer who underwent PG without a lymphadenectomy as a palliative surgery for reasons such as bleeding or obstruction with poor general conditions, but who were outside the indication for PG. The following reconstruction methods after PG were performed: Esophagogastrostomy (EG), which involves anastomosis of the esophagus with the anterior wall of the remaining stomach, where as much of the side of the greater curvature of the stomach as possible is preserved during resection (15 cm or more). The remaining upper part of the greater curvature is sutured to the diaphragm and fixed dorsally. In jejunal interposition (JI), a 10 cm diameter ρ-loop is created at the jejunum, an end-to-side esophageal-jejunal anastomosis is created, and an anastomosis is made with the anterior wall of the remaining stomach, with a 5 cm duct. Jejunal pouch interposition (JPI) involves the creation and interpositioning of a 10 cm jejunal pouch. The selection of procedure was not randomized, but was not made according to background factors. We retrospectively examined the clinicopathological characteristics of the early stage gastric cancers, factors related to the surgery, postoperative complaints, recurrence, and prognosis. To examine the postoperative complaints that are common in this type of surgery, we drew information from regular postoperative observations, questionnaires, and yearly postcard surveys. Through these methods, we evaluated the following factors over the first year after surgery: weight loss and the presence of digestive symptoms, such as heartburn, nausea, heaviness after meals, dysphagia, abdominal pain, and diarrhea. Furthermore, a comparison was made between 93 cases that underwent PG (EG: 60 cases, JI: 21 cases, JPI: 12 cases) and 38 contemporaneous cases that underwent TG for histologically diagnosed early upper gastric cancer.
Terminology used is in accordance with the 3rd English edition of the Japanese Classification of Gastric Carcinoma [8]. Statistical analyses were conducted with the Pearson’s chi-squared test. The survival rate was calculated using the Kaplan-Meier method and examined with the generalized Log-rank test. In all cases, p
