In this study, we showed DFT has the advantages in less body weight loss, less reflex esophagitis, and less gastric residual after proximal gastrectomy. In the past, total gastrectomy was recommended rather than proximal gastrectomy for upper gastric cancers, since that the most of upper gastric cancers were advanced at the time of diagnosis and prognosis of this population was very poor(8-12). Also, proximal gastrectomy was not recommended in terms of postoperative morbidity and quality of life (QOL), since frequency of reflux esophagitis and heartburn after proximal gastrectomy were significantly higher than those after total gastrectomy, and no benefit was observed in the point of body weight loss compared with total gastrectomy(16, 17, 34). Furthermore, it was reported that QOL after proximal gastrectomy is worse than total gastrectomy because of high frequency of nausea and vomiting(17). However, most of reconstructive procedures after proximal gastrectomy in these previous studies were esophago-gastrostomy without any anti-reflex mechanisms. Recently, it has been reported that prognosis after proximal gastrectomy is oncologically similar with that of total gastrectomy(34, 35), and it was showed that proximal gastrectomy with supra-pancreatic lymph nodes dissection has favorable long-term outcome in Japan(14). As a result, the number of proximal gastrectomy has been increasing in Japan. In addition, nutritional benefit of proximal gastrectomy compared with total gastrectomy was recently reported(27-29, 36). Furthermore, several types of reconstructive procedures which can prevent regurgitation, such as JIP(19-21), jejunal pouch reconstruction(22, 23), gastric tube reconstruction(24), DEG with fundoplication(18, 25), DTR(26-29), and DFT (30) (31) (32), were developed. However, it was not clear which reconstructive procedure has advantages of postoperative QOL. In this study, we retrospectively analyzed our consecutive case series for proximal gastrectomy, with particular focus on postoperative body weight maintenance, nutritional status, and gastric remnant functional preservation. In this study, we showed that DFT is the most effective reconstructive procedure to prevent reflux esophagitis, since no reflux esophagitis was observed in DFT group and reconstruction with anti-reflux procedure other than DFT has some cases of reflux esophagitis.
Also, we showed that the rate of anastomotic stenosis after DFT (8.3%) was less frequent in comparison to other reconstruction procedures. However, it should be careful in interpreting of this anastomotic stenosis date. It is generally accepted that circular stapler is widely used for esophago-jejunostomy(37-39) and the stricture rate with a stapler anastomosis was reported to be high compared to hand-sewn anastomosis(40-42). Since esophago-gastrostomy in DFT is performed by hand-sewn, it makes anastomosis soft and flexible, and can prevents the anastomotic stenosis(43). In other words, the less anastomotic stenosis rate in DFT may be due to hand-sewn anastomosis, not by DFT procedure itself. The rate of anastomotic stenosis after DFT has been reported to be 5.5％-9％(32, 43, 44) and 8.3% in the present study. Therefore, we still need to improve and modify a DFT procedure which can prevent anastomotic stenosis more completely. Now, we are employing Gambee’s method for suturing anterior wall of esophago-gastrostomy in the DFT reconstruction, instead of layer-to-layer running suture. Moreover, there are some reports that DFT was performed by laparoscopic surgery, it may have more benefit due to the minimally invasive surgery(32, 36). However, laparoscopic DFT is cumbersome due to its restriction of movement, surgeons need to be an expert in laparoscopic suturing skill. However, it may be resolved by robotic surgery(45). In this study, 13 cases of DFT were performed by robotic assisted surgery and we have good achievement in robotic DFT.
In this study, we showed that post-operative body weight loss after Double Flap Technique is the best outcome. We believe that one possible reason to improve body weight loss in DFT is less regurgitation and less gastric residual in comparison to other procedures. Unfortunately, we were not able to show solid advantage of DFT in postoperative nutritional status within hematological examination compared to other reconstructive procedures, although there was minor advantage in DFT group for albumin change.
Although the present study has provided some important information for clinical practice, it has some limitations. In particular, this was a retrospective study with a small sample size at a single institution. Further accumulation of cases is required. Second, the study may have bias, because we did not evaluate the size of remnant stomach, which may affect to post-operative body weight loss and nutritional status.