In this study, we compared the clinical outcomes between our novel method and conventional method following LPG. All patients in this study were completed in curative resection by LPG. In comparison between the Novel and Conventional group, the Novel group tended to have more advanced cancer patients. There were no differences in the operation time and the incidence of postoperative complications between the two groups, whereas the amount of blood loss in the Novel group was less than those in the conventional group. Postoperative anastomosis-related complications such as leakage and stenosis did not occur in this study. Although there was no significant difference, the frequency of postoperative reflux esophagitis in the Novel group was lower than those in the Conventional group. The LPG with our novel reconstruction method for proximal EGC is a simple, safe technique that may prevent anastomosis-related complications, especially esophageal reflux.
Regarding the surgical treatment for EGC in the upper third of the stomach, the following three issues have been mainly discussed; the first issue is the operation method, TG or PG. The second is the reconstruction method following PG. The third is the oncological safety in PG.
In the Western countries, TG is more often performed for proximal ECG. The following concerns may be the reason why PG is considered to inferior to TG for proximal gastric cancer. The first concern is whether the quality of life after PG is better than after TG, regarding loss of body weight and suffering malnutrition. The second is postoperative anastomosis-related complications including, anastomotic leakage and stenosis. The third is the occurrence of severe reflux esophagitis after PG. Therefore, many surgeons in the Western countries have chosen to perform TG even for upper-third EGC. To improve these concerns, various reconstruction procedures following PG have been developing, especially in Japan. Until now, three reconstruction methods, including double-tract reconstruction (DT), jejunal interposition (JI), and esophagogastrostomy, have been popularly performed following PG in Japan. However, a standard reconstruction procedure following PG has not been established because each procedure has some disadvantages.
Esophagogastrostomy is the simplest reconstruction procedure than other procedures, DT and JI. However, esophagogastrostomy have a high risk of reflux esophagitis and anastomotic stenosis. Therefore, several procedures for preventing reflux esophagitis in esophagogastrostomy have been reported. Okabe et al. reported the reconstruction method with an esophagogastrostomy using a knifeless linear stapler and hand suturing . This procedure is similar to our method in that the use of linear stapler and the fixation of the esophagus onto the anterior wall of the remnant stomach. However, their procedure is end-to-side anastomosis by continuous hand suturing. Hand suturing of anastomosis is likely the cause of anastomotic stenosis. Yamashita et al. reported a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY) . They performed side overlap esophagogastrostomy by linear stapler rotated counterclockwise on its axis, suturing the gastric wall to the left side of the esophagus. This method is also easily procedure like our method, but concerns about reflux still remain due to the patients’ position. Kamikawa et al. described a novel esophagogastrostomy procedure with double-flap technique , and this procedure was applied to LPG [23–25]. Although the short-term outcomes regarding reflux prevention following these procedures have been reported to be satisfactory, these techniques are very complicated. So, these challenging techniques may prevent the widespread use of LPG for upper one-third of EGC.
As shown in the present study, our novel procedure is so simple and can be easily and safely performed even younger surgeons who are familiar with the laparoscopic standard technique. Characteristics of our novel reconstruction method are as follows: (1) reconstruction by a long and narrow gastric tube with the sufficient capacity; (2) making a pseudo-gastric angle by long gastric tube; (3) a pseudo-fundus by making gastric tube with widening of the proximal side like a cobra’s head; (4) preserving the excretory function of residual stomach by avoidance of No.5 and No.6 node dissection around the pyloric ring; (5) the anastomosis by on-lay method with tight suturing between the esophageal muscularis fascia and the gastric tube flatten the esophagus; (6) fixing the esophagus to bilateral crus of diaphragm for the prevention of twisting and lifting of the esophageal stump. In this study, reflux esophagitis of grade C was observed in only three patients (10%) because of these additional reflux prevention systems. Besides, we noted no other anastomosis-related complications during this study. These results suggest that our novel reconstruction method is a feasible procedure as the reconstruction following PG.
Several studies have concluded that long-term outcomes of open PG for proximal ECG were not shown to be different from those of open TG [10, 26, 27]. Oncological safety in LPG might have not become a major concern due to these previous results. Thus, there is little evidence of oncological safety of LPG. Ahn et al. reported that overall survival for proximal gastric cancer was similar when comparing LPG and LTG . In our study, recurrence was observed in only 2 patients with advanced proximal gastric cancer. We have been expanding operative indication from early to advanced gastric cancer, recently. We consider that LPG may be an oncologically acceptable procedure for stage I and IIA at least. Large sample size of patients is necessary to confirm these considerations.
The present study has some limitations. First, this was a retrospective and limited study at a single institution. Second, the nutritional status of patients was not examined in this study. Third, the comparison of outcomes did not include TG. Further examination and longer follow up of patients are needed.