B. P. Stahl1, J. B. Rose1, C. M. Contreras1, M. J. Heslin1, T. N. Wang1, S. Reddy1 1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA
Introduction: Surgical resection is a mainstay for treating gastric cancer. There is significant controversy surrounding the appropriate operation to maximize oncological benefit and functional outcome for proximal gastric cancer. Some advocate total gastrectomy (TG) with roux-en Y esophagojejunostomy reconstruction claiming that this operation provides optimal lymph node staging for this disease and eliminates post-operative reflux. Others favor proximal gastrectomy (PG) with esophagogastric reconstruction hoping that the residual gastric reservoir will improve nutrition. We sought to address this question by reviewing oncological, perioperative, and functional outcomes of patients undergoing these two operations for proximal gastric cancer.
Methods: We performed a systematic review and meta-analysis of patients undergoing TG and PG for gastric cancer using PubMed, Embase, and the Cochrane Library from 2007 to 2018 with the MeSH terms “proximal”; “total”; and “gastrectomy” in English-language publications. We identified 659 results; 359 remained after duplicates were purged. From this dataset, 23 articles were selected for the present study. Studies were evaluated for quality with the Newcastle-Ottawa scale for non-randomized evaluations and via the Jadad scale for randomized-control trials.
Results: 23 articles were included in the quantitative synthesis (17 retrospective and 6 prospective studies) with 3227 patients (1984 TG and 1243 PG). Most of the studies originated from Asia (Japan 13, Korea 5, China 2, Italy 1, India 1, United States 1) with patients cared for from 1990-2012. Most of the patients (96%) had Stage I or II gastric cancer. 30% (6/20) of the studies used perioperative chemotherapy. Median follow up was reported in 19/23 studies (range 17-60 months). TG retrieved a larger number of lymph nodes (OR 13.11, P<0.00001; FIGURE A), had fewer anastomotic stenoses (OR 3.13, P=0.0004; FIGURE B), and had less post-operative reflux symptoms (OR 2.72, P=0.01; FIGURE C) compared to PG. The two operations had similar complication (FIGURE D) and 5-year overall survival rates (FIGURE E). Mortality was similar between the two operations (PG 3.5% vs. TG 1.3%, P=0.66).
Conclusion: Although TG obtains a greater number of lymph nodes, both operations offer similar long-term overall survival—raising the question of whether these additional distal gastric resected lymph nodes are important in early stage proximal gastric cancer. PG is a safe and effective operation for early stage proximal gastric cancer if surgeons are willing to accept postoperative gastric reflux and anastomotic stenosis. These findings will need to be evaluated in advanced gastric cancer.
