Functional and nutritional outcomes after gastric cancer surgery

Abstract

Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.

Keywords: Function-preserving gastrectomy; esophagogastrostomy with double-flap technique (esophagogastrostomy with DFT); gastric cancer (GC); proximal gastrectomy (PG); pylorus-preserving gastrectomy (PPG).

Figure 1

Surgical concept of PPG for GC in the middle stomach. The proximal remnant stomach is transected on the demarcation line between the right and left gastroepiploic arteries. The distal stomach is divided 4 to 5 cm proximal to the pyloric ring. The supra-/infra-pyloric vessels and the pyloric branch of the vagus nerve are preserved to maintain the blood supply and function of the pyloric cuff. PPG, pylorus-preserving gastrectomy; GC, gastric cancer. Reproduced from ref (4).

Figure 2

Esophagogastrostomy with double-flap technique (DFT). (A) Creation of the seromuscular double flaps (2.5 cm wide × 3.5 cm high) on the anterior wall of the remnant stomach. (B) Fixation between the posterior wall of the esophagus and the superior edge of the mucosal window (red arrows). Suturing between all layers of the posterior esophageal wall and superior opening of the mucosa on the gastric remnant. (C) Suturing between the anterior wall of the esophagus and the inferior opening of the gastric wall. (D) Coverage of the esophagogastric anastomosis by seromuscular flaps. The completed anastomosis is Y-shaped. Reproduced from ref (4).