Esophagogastrostomy reconstruction is a traditional reconstruction method after proximal gastrectomy. However, esophagogastrostomy is associated with a high incidence of postoperative reflux esophagitis. To address this disadvantage, several modified reconstruction methods, including double tract reconstruction, have been attempted.
The safety and feasibility of double tract reconstruction after proximal gastrectomy have been of great concern in recent years. In the present study, the results showed that there was no significant difference in blood loss volume, length of postoperative hospital stay or postoperative complications between esophagogastrostomy and double tract reconstruction. The operation duration was longer in the double tract reconstruction group than in the esophagogastrostomy group in this study. Considering that the double tract reconstruction procedure is more complex than the esophagogastrostomy procedure, it is reasonable that the operation duration of double tract reconstruction was longer than that of esophagogastrostomy. On the other hand, whether double tract reconstruction causes a high rate of complications because of the technical complexity and increased number of anastomoses has been questioned [10, 11, 19]. In the present study, postoperative complications, blood loss volume and length of postoperative hospital stay were all comparable between the two reconstruction methods. These results suggest that the complexity of the surgical procedure dose not increase the risk of the operation.
The anti-reflux function of double tract reconstruction after proximal gastrectomy has been investigated in previous studies [12, 13]. However, most of the results are based on studies with exceedingly small samples. In the present study, the rates of reflux esophagitis in the esophagogastrostomy group and double tract reconstruction group were 30.8% and 8.0%, respectively (P = 0.032). Moreover, multivariate logistic regression analysis showed that the reconstruction method was the only independent risk factor for reflux esophagitis (P = 0.004). Double tract reconstruction is a protective factor against postoperative reflux esophagitis after proximal gastrectomy. Considering the reconstruction procedure, it is possible that the mechanism of anti-reflux function is mainly attributed to the lifted jejunum between esophagojejunostomy and gastrojejunostomy [20, 21].
Many studies have reported nutritional status after proximal gastrectomy [13, 22, 23]. However, postoperative quality of life after proximal gastrectomy has rarely been reported before. Thus, the present study compared quality of life after proximal gastrectomy with the EORTC QLQ-C30 version 3.0 and QLQ-STO22 questionnaires between esophagogastrostomy and double tract reconstruction. According to the EORTC scoring manual, a higher score represented a better level of functioning, or a worse level of symptoms . In the present study, double tract reconstruction had obvious advantages over esophagogastrostomy based on the EORTC QLQ-C30 questionnaire, including in global health status, emotional functioning, nausea and vomiting, pain, insomnia, and appetite loss (Table 5). For the EORTC QLQ-STO22 questionnaire, symptoms including dysphagia, pain, reflux, eating, anxiety, dry mouth, and taste were much milder in the double tract reconstruction group than in the esophagogastrostomy group (Table 6). The mechanism of the anti-reflux function of double tract reconstruction has been discussed in the previous paragraph of this section. Furthermore, previous studies reported that the prevention of reflux esophagitis might improve the psychological, physical, and social functioning of patients . Moreover, the prevention of reflux esophagitis could also relieve symptoms such as nausea, vomiting, pain, insomnia, appetite loss, dysphagia, eating, anxiety, and dry mouth [26–31]. Therefore, the better scores in the double tract reconstruction group might be due to the superiority of the surgical procedure itself in preventing reflux esophagitis after proximal gastrectomy.
Considering that the global health status score in the EORTC QLQ-C30 questionnaire can reflect overall quality of life, a linear regression analysis was performed to investigate the related factors . The results showed that reconstruction method (P < 0.001), postoperative complications (P < 0.001), reflux esophagitis (P = 0.003), and operation duration (P = 0.001) had a linear relationship with the global health status score (Table 8). The mechanism of double tract reconstruction in preventing reflux esophagitis and improving quality of life has been discussed in the previous paragraph. Furthermore, some studies have reported that postoperative complications could induce physical and mental discomfort and impair quality of life [32, 33]. Interestingly, operation duration was also identified in the equation. The operation duration could reflect how elaborate the operation was. Theoretically, an elaborate operation could protect the nerves better, and better preserve organ function [34–36]. Therefore, a longer operation duration might improve quality of life after the operation.
The present study also has some limitations. First, selection bias was difficult to avoid because this was a retrospective study. The pathological stage was not comparable between the two groups, resulting in differences in tumor size, degree of LND, PNI, and adjuvant chemotherapy. This phenomenon was mainly caused by the different choices of the patients. In our hospital, the reconstruction method was discussed and determined by both the patients and surgeons. Patients with early-stage disease were more likely to choose double tract reconstruction after learning about its superiority because these patients might pay more attention to quality of life after the operation. Thus, the shared decision-making method might be the cause of the bias. However, multivariable logistic regression analysis and multiple linear regression analysis could neutralize the confounding effects of these factors. Second, the sample size of the present study was not large enough, which might make the results of this study less convincing. Further large-scale, prospective, randomized controlled trial is needed to validate the results of the study.