The incidence rate of proximal gastric cancer has increased significantly in the world in the past 20 years. [24, 25]. The choice and safety of excision methods for upper gastric carcinoma have become one of the hot topics in research. TG with D2 lymphadenectomy has become the standard surgical procedure for patients with advanced proximal gastric cancer. Patients with EGC usually have long postoperative survival and low recurrence rate . Therefore, it is very important for EGC patients to ensure their postoperative quality of life . Multiple studies have shown that patients who undergo radical PG have a better quality of life after surgery than those who undergo TG [28–30]. The Japanese Gastric Cancer Treatment Guidelines suggest that PG should be used in patients with proximal EGC, and the residual stomach should be retained at least 50% . Usually, the residual stomach of 12cm or more along the lesser curvature and 25cm or more along the greater curvature from the pylorus ring is preserved .
With the development of laparoscopic instruments and the progress of technology, the application of laparoscopy in proximal gastric cancer is bound to be one of the key directions in the future. Our previous study reported the short-term efficacy of open PG with PJIDTR . In particular, the efficacy of LPG with PJIDTR remains unclear due to the lack of short and long-term studies.
The application of PG to proximal EGC has been limited due to the following four main concerns: oncologic safety, nutrition benefits, gastroesophageal reflux and anastomotic stenosis. The results showed that there was no significant difference between the two groups in operation time, bleeding volume, first anal exhaust time and postoperative hospital stay. Although LPG with PJIDTR requires three anastomoses and the procedures seem to be more complicated, there was no significant difference in anastomotic complications between the two surgical methods (6% vs. 4%) (Table 2). Stricture of the residual gastrojejunal anastomosis after LPG with DTR will lead to food flow without passing through the residual stomach. Ahn SH et al.  performed a routine gastric emptying scan at three months after the operation. The relative ratio of food flow from the stomach to the small intestine after DTR was 3:2. Yamashita K et al.  evaluated the actual food flow one year after DTR by digestive tract radiography for the first time, and 17.5% of the patients had food directly entering the small intestine without passing through the residual stomach. Presumably, there are several reasons why food doesn't pass through the residual stomach. First, the retained residual stomach volume is too small, resulting in the residual stomach pressure is greater than the jejunal route; Second, the direction and size of the residual gastrojejunal anastomosis lead to easier food flow into the jejunum; Third, gastrojejunal anastomotic stenosis, causing food to be unable to enter the residual stomach. No relevant anastomotic stenosis was found in our study because of the large side-to-side anastomosis and and more than half of the gastric remnant.
When more than half stomach can be preserved, the PG is chosen, because the nutritional status after the PG were shown to be better than after the TG by many studies [9–11]. According to PGSAS, PG was superior to TG in weight loss, dietary supplementation, diarrhea and dumping syndrome . The reason is that the presence of gastric remnant reduces the incidence of angastric anemia due to vitamin B12 and iron absorption disorders. The presence of pylorus reduces the incidence of bile reflux and dumping syndrome. As this study shows (Table 3), the nutrition indexes at one year after surgery in the LPG group were significantly better than LTG group (P < 0.05). LPG was superior to LTG in controlling skeletal muscle loss, maintaining stable body weight, reducing anemia, and improving quality of life.
In this study, we analyzed the surgical outcomes of LPG with PJIDTR in 50 patients with proximal EGC. To our knowledge, this is first report to describe the application of LPG with PJIDTR for proximal EGC, which shows good postoperative effects, especially the reduction of reflux symptoms. Only one patient had grade II reflux symptoms in LPG group. This good result reflects the fact that PJIDTR in LPG associates with fewer reflux symptoms than LPG with other reconstruction methods. Several previous studies have applied direct esophagogastric anastomosis as the reconstruction method, probably because it is simple and needs only one anastomosis. Many anti-reflux procedures are used to prevent reflux esophagitis, such as gastric tube formation, fundoplication, esophagopexy with crural repair and pyloroplasty. However, all these methods involved esophagogastrostomy, and the results were disappointing since the rate of reflux esophagitis were still high [34–36]. A good alternative to esophagogastrostomy reconstruction after PG is the PJIDTR, which is very effective anti-reflux reconstruction. At our institution, LPG with PJIDTR was also performed since February 2010 and showed a low rate of early postoperative complications, especially anti-reflux effect and nutritional recovery .
We found that the oncological safety of LPG with PJIDTR was satisfactory: no tumor recurrence was observed. It should be noted that most of the five LTG patients who died were elderly with underlying cardiopulmonary disease. There was no significant difference in survival rate between the two groups. The results are consistent with relevant studies [4, 12]. Systematic meta-analysis compared TG and PG, it was concluded that TG and PG had similar overall survival outcomes for proximal gastric cancer .
This retrospective cohort study had the following three limitations. First, retrospective studies have a lower level of evidence than prospective studies. Second, we didn’t assess the quality of life of the patients because it was not fully followed up by using a validated questionnaire, Third, the sample size of this study can be further expanded. However, to our knowledge, this is the first retrospective study of LPG with PJIDTR. These encouraging data lead us to plan phase III multicenter prospective randomized clinical trial about LPG with PJIDTR.