Previous study reported that subtotal gastrectomy has a lower incidence of DGE of only 3.1%[10]. Thus, we hypothesized that a less remnant stomach might lead to a lower incidence of DGE and attempted subtotal gastrectomy for PD. Conventional PD surgery requires removal of approximately 1/3 of the distal stomach. Compared with conventional PD, subtotal gastrectomy PD removes approximately 3/4 of the stomach. Several investigators have reported that the subtotal gastrectomy in PD surgery may reduce the incidence of postoperative DGE. Yusuke et al. compared the incidence of DGE between subtotal stomach-preserving PD and antrectomy-combined PD and finally concluded that antrectomy-combined PD leads to a lower incidence of DGE. Philip et al.[11] reported that 4/5 gastrectomy in patients undergoing PD reduces the incidence of DGE. Toshihiko et al[12]. reported that Roux-en-Y reconstruction following gastric cancer was more frequently followed by Roux stasis in the antrum than in the midstomach.
Our study compared the short-term outcomes of subtotal gastrectomy PD and conventional PD. Compared with conventional PD, subtotal gastrectomy PD resulted in a lower incidence of DGE B/C (17.7% vs. 8.7%) and a shorter hospital stay. This result is similar to previous studies. Due to the lower incidence of DGE, subtotal gastrectomy PD had a shorter hospital stay. Subtotal gastrectomy PD was similar to conventional PD in terms of intraoperative bleeding, operative time and in-hospital mortality. This means that although PD removed more stomach, it did not increase the morbidity and mortality of patients.
Currently, DGE is thought to be mainly caused by pyloric dysfunction and impairment of the propulsive action of the stomach[13]. Some publications have reported that pylorus-resecting PD results in a lower incidence of DGE than pylorus-preserving PD[6, 14]. The elimination of pyloric dysfunction caused by pyloric resection may be the reason for the lower incidence of DGE in pyloric-resecting PD. Additionally, the smaller remnant stomach volume increases the mechanical stimulation of the stomach by food, which can promote the vago-vagal reflex and the local reflex of the intramural plexus, thereby enhancing gastric peristalsis and promoting gastric emptying[15].
Our study did not analyze the long-term quality of life of patients after PD. Yusuke et al. compared the nutritional status after PD between the antrectomy-combined PD group and the subtotal stomach-preserving PD group. The nutritional status of the two groups at 3, 6, and 12 months after surgery was comparable. Santoro et al. reported that most patients who underwent subtotal gastrectomy showed no significant difference in long-term quality of life after surgery compared with preoperative patients[16]. Philip et al reported that subtotal gastrectomy PD patients with subtotal gastrectomy lost more body weight 1.5 months after surgery than conventional PD patients. However, there was no significant difference in weight loss between the two groups at 3 months and 6 months after surgery. Additionally, most of the patients who received PD in our center did not complain of obvious discomfort in the postoperative outpatient follow-up. Therefore, our center initially believes that subtotal gastrectomy PD has little adverse effect on the long-term quality of life of patients.
In the multivariate regression analysis, subtotal conventional PD and elevated BMI were risk factors for DGE. Previous studies have also confirmed that high BMI is associated with an increased risk of DGE[17, 18]. A high BMI can lead to the accumulation of fat around the patient's organs, which increases the difficulty of PD surgery.
This study preliminarily confirmed that subtotal gastric resection of PD can effectively reduce the incidence of postoperative DGE, and the level of safety is similar to that of conventional PD. However, the study still has some limitations, as it was a single-center, retrospective cohort study. Further multicenter prospective studies are needed in the future. Additionally, further long-term quality of life assessments should be conducted in future investigations.