74 patients with AEG (Siewert II or III) were recruited consecutively at First Affiliated Hospital of Zhengzhou University from July 2013 to December 2017. From May 2015 to December 2017, PG-TVT was performed on 44 patients with clinical diagnosis of T1-4N0-3M0 at the preoperative evaluation according to the 8th edition of American Joint Committee on Cancer Tumor-node-metastasis (AJCC-TNM) Staging System of Gastric Carcinoma. 30 patients with T1-4N0-3M0 located in or involving the upper third of the stomach received TG from July 2013 to December 2015 as the control group. From January 2016 to 2017, TG was also performed on another 17 patients with the same indications as in the previous period. However, the latter period was not selected because the number of TG-TVT cases had gradually increased during that period. Certain settings, including the surgeon’s preference in relation to adopting the procedure, had been taken into considerations to avoid selection bias. All patients were operated by the same surgical team.
All patients were in stable and operable condition at operation. Written informed consent was obtained from all of them. This study is a retrospective study using clinicopathological, surgical, and follow-up data, and has approved by the institutional review board at the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
Surgical Procedure of PG and PG-TVT Reconstruction
The detailed surgical procedure of PG and PG-TVT reconstruction is described as below (Figure 1). After lymph node dissection is completed, the first step of procedure is to locate tumor lesion and determine resection region including upper (G1) and lower (G2) resection margins. As shown in Figure 1A, an example of a primary tumor lesion located along lesser curvature (shown in black) is used to present the resection region with upper G1 and lower G2 margins at distance of no less than 2cm and 5cm respectively from tumor lesion. The before-mentioned distances are measured on tension-free gastric body. Based on the after-mentioned estimation on resection region, the upper resection line is defined with cutting line G1 (black), and then a lower resection line is defined with the first cutting line L1 (red line) which is perpendicular to greater curvature and second cutting line L2 (blue line) which is at 30 degrees relative to line L1 (Figure 1B). The crossing point of line L2 on lesser curvature is supposed to be no less than 8cm from pyloric sphincter. Consequently, a solid linear path of L1 and L2 as shown in figure 1B indicates the lower resection line. A proximal gastrectomy was performed along the above solid linear path with a linear cutting closure (Figure 1B). Thirdly, as shown in figure 1C, on the exposed flattened side of the remnant gastric body, a curve line (blue) is drawn 2cm from greater curvature with 3 parallel lines (red) (2cm from each other) perpendicular to it. The midpoints of those three parallel lines are marked as shown in Figure 1C. Similar curve line, other three parallel lines and mid-points are also drawn on the back side of the remnant gastric body (not shown in Figure 1C). Then, three stitches are done along those midpoints on both sides (Figure 1D) so that the gastric wall between those midpoints of both sides will be folded towards gastric cavity to form a Triangle-Valve shaped bulge when those sutures are knotted (Figure 1E). Finally, the distal remnant stomach is anastomosed to the esophageal end through point H (Figure 1E). The triangle valve shaped bulge as shown in Figure 1F functions similarly to cardia as an anti-reflux design.
Surgical Procedure of TG and Roux-en-Y (R-Y) Reconstruction
TG radical resection was performed by following Japanese gastric cancer treatment guidelines . The resection distance from the upper and lower margins of tumor must be ≥ 2cm, and D2 lymph node dissection must be ensured [24, 25]. After that, Roux-en-Y reconstruction was completed . Jejunum was separated 20 cm below the ligament of Treitz and esophageal distal jejunal anastomosis was performed. Then proximal jejunum was anastomosed with the distal jejunum 40 cm below the anastomosis.
Clinical Parameters and Surgical Outcomes
Patients’ clinical features were obtained from their medical records: age, sex, body mass index (BMI), Siewert type, tumor size, histological type, pathological TNM stage, history of abdominal surgery, preoperative chemotherapy, and postoperative adjuvant chemotherapy. Surgical findings such as operation time, estimated blood loss, combined with laparoscopic-assisted, extent of lymph node dissection, number of retrieved lymph nodes, residual tumor (R), postoperative complications, and postoperative hospital stay were retrieved from their records as well.
Follow-up and Postoperative Nutritional Status
All patients were followed up for 6 months. Reflux Disease Questionnaire (RDQ) was used to evaluate reflux esophagitis. The frequency and severity of the upper gastrointestinal symptoms (heartburn, regurgitation, noncardiogenic chest pain, and regurgitation) were asked in 6 months after surgery. Patients with RDQ score of ≥12 points were diagnosed with gastroesophageal reflux disease (GERD) . To evaluate postoperative nutritional status, changes in body weight and biochemical data such as serum concentrations of total protein (TP), albumin (Alb), hemoglobin (Hb), prealbumin (PA) were examined at 7days, and 6 months after surgery.
Categorical variables were compared by using chi-square test or Fisher's Exact Test, and continuous data were compared by using Student’s t-test or Mann-Whitney U test. Postoperative changes in weight, TP, Alb, Hb and PA were compared using repeated measures ANOVA and Post-Hoc Tests for the multiple comparisons. All analysis was conducted using RStudio software (Version 1.1.456, 2009-2018 RStudio Inc.). All Statistical tests were two-sided, and p < 0.05 was considered statistically significant.