In this study, we analyzed the results of the surgical outcomes of 33 patients who had Siewert II/III AEG underwent PJIRSTR. The PJIRSTR technique was first proposed by our research team in 2016[8]. To our knowledge, this is the first detailed description of the PJIRSTR technique. Based on the results of our analysis, PJIRSTR effectively solves the problem of reflux after PG. It is an acceptable treatment method for the Siewert II/ III AEG.
According to the Japanese gastric cancer treatment guidelines (Fifth edition), for early AEG, if more than half of the stomach after R0 resection can be preserved, PG can be selected as the surgical method[9]. However, it is still unclear whether PG can be performed for advanced AEG. Sugoor et al.[10] reported that as long as sufficient surgical resection margins are ensured and enough remnant stomach is preserved, PG can be selected even for advanced proximal-third gastric cancer. Haruta et al.[11] believed that patients with advanced AEG whose tumor length is < 4 cm could undergo PG.
As a functional preservation surgery, PG has some irreplaceable advantages compared with TG. First, PG ensures that food stays in the residual stomach for preliminary digestion, and then further digestion through the duodenum, which is conducive to full absorption in the jejunum and the nutritional status of patients after surgery. Second, PG provides a better pathway for further endoscopic treatment such as endoscopic retrograde cholangiopancreatography (ERCP) than TG. A recently conducted multi-center, prospective study reported that in terms of long-term efficacy, the 3-year survival rates of PG and TG were similar (96% and 92%, respectively), but the incidence of reflux esophagitis was significantly higher in the TG than PG group (14.5% vs. 5.4%; P = 0.02)[12]. Thus, after ensuring oncological safety, if we improve the PG approach to reduce the incidence of postoperative complications such as reflux esophagitis and anastomotic stenosis to a level similar to or even lower than that of TG, PG has the potential to become the standard surgical method for AEG.
Yamashita[13] found that double-tract reconstruction (DTR), which allows food to pass through the residual stomach into the duodenum, can effectively maintain postoperative nutritional status. However, some studies indicated that dietary bolus after DTR cannot enter the duodenum through the residual stomach as scheduled, rather escape through the jejunum route, which ultimately results in nutritional results similar to TG with Roux-en-Y reconstruction (TGRY)[14, 15]. In addition, a retrospective study have recently demonstrated DTR and esophagogastrostomy has similar nutritional outcomes and QOL[16]. PJIRSTR completely blocked the passage of the proximal jejunum and avoided food escaping through the jejunum. Futhermore, When food passes through the duodenum, it is fully mixed with bile and pancreatic juice, and stimulates the secretion and release of hormones such as pancreatic secretin and cholecystokinin in the gastrointestinal tract, which is conducive to the digestion and absorption of food. Compared to jejunal interposition (JI), PJIRSTR, a technique similar to RY, is relatively easy to perform. In addition, when cancer of the remnant stomach is found, PJIRSTR can deal better with the remnant stomach than JI. In terms of the length of the interposed jejunum, Tokunaga suggested that it should be < 10 cm[17]. Some scholars have suggested that the ideal length is 10–15 cm[18–20], otherwise, it may cause intestinal food stasis and inconvenience during postoperative endoscopy. However, according to our clinical experience, when the length of the interposed jejunum is 12–15 cm, the above problems can be solved.
In this context, we speculated that if PJIRSTR could effectively solve long-term complications of postoperative reflux and anastomotic stenosis, it may become an attractive treatment method for Siewert II/III AEG. In our study, only 2 of the 33 patients (3.1%) had Visick grade II reflux symptoms from the follow-up results. In addition, no signs of reflux esophagitis were reported by gastroscopy in all patients after surgery. The postoperative anti-reflux effect of this method is completely comparable with some anti-reflux surgery methods that have been reported so far. For example, the incidence of reflux esophagitis after side-overlap esophagogastrostomy (SOFY) was 10%. However, the procedure requires an experienced surgeon to perform it under a laparoscope[21]. The incidence of reflux esophagitis after the double-flap technique (DFT) was 0%, and the incidence of reflux symptoms was 10%[22]. This technology has a good effect in preventing reflux esophagitis, but technical difficulties and the risk of anastomotic stenosis is relatively high. Our analysis showed that PJIRSTR has better anti-reflux effect than other techniques and may be related to the following two mechanisms that have a dual anti-reflux effect. First, side-to-side anastomosis was performed between the jejunum and the anterior wall of the remnant stomach, while keeping the anastomosis 3–5 cm away from the stump of the remnant stomach. This method of anastomosis formed an “artificial stomach fundus” structure, effectively blocking the food or digestive fluid from flowing into the esophagus. Second, is the anti-reflux effect of jejunum interposition; PJIRSTR completely blocked the passage of the proximal jejunum, making alkaline reflux esophagitis almost impossible.
In this study, we performed adjuvant chemotherapy for all patients whose postoperative pathology was not staged I at that time. Therefore, 23 of 33 patients underwent chemotherapy. The 3-5-year cumulative overall survival rates were 90.9% and 78.8%, respectively, indicating that the technique was feasible in terms of oncology safety.
In our study, we performed PJIRSTR, which achieved satisfactory surgical and postoperative results. No death during operation or severe perioperative complications were recorded in any of the 33 patients. Both early postoperative complications(9.1%) and late complications(9.1%) were low compared to DTR[23]. For the postoperative nutritional status of the patients, the weight and hemoglobin of the patients did not return to the preoperative level at postoperative 18 months, which may be related to the status of advanced tumors in some patients. In our study, the average weight loss was 13.5%, 11.8%, and 10% at postoperative 3, 6, and 12 months, respectively. Difficulty maintaining weight is a typical feature after gastrectomy, which is connected with reduced stomach volume[23]. However, all the nutritional indicators have been rising after surgery.
There are several limitations to this study. First, this was a retrospective study prone to inherent bias. second, all cases had performed laparotomy, we should also apply this technique to laparoscopic or robotic surgery to evaluate its feasibility. Third, the sample size of the study is relatively small, and more multi-center, prospective clinical data support is needed to validate the findings.
In conclusion, we report here our novel reconstruction method after PG—PJIRSTR—that shows satisfactory outcomes after the operation. Most importantly, PJIRSTR effectively addressed the problems of postoperative reflux and reflux esophagitis and improved the postoperative quality of life of patients. However, multi-center and prospective randomized trials are needed to verify its clinical application value.