Effect of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction vs Total Gastrectomy on Hemoglobin Level and Vitamin B₁₂ Supplementation in Upper-Third Early Gastric Cancer

Abstract

ImportancePatients undergoing proximal gastrectomy (PG) with double-tract reconstruction (DTR) have been reported to have an incidence of reflux esophagitis that is as low as that observed after total gastrectomy (TG). It is unclear whether PG has an advantage over TG for the treatment of patients with upper early gastric cancer (GC).ObjectiveTo evaluate the effect of laparoscopic PG with DTR (LPG-DTR) vs laparoscopic TG (LTG) on levels of hemoglobin and vitamin B12 supplementation required among patients with clinically early GC in the upper third of the stomach (upper-third early GC).Design, Setting, and ParticipantsThis multicenter open-label superiority randomized clinical trial was conducted at 10 institutions in Korea. A total of 138 patients with upper-third cT1N0M0 GC were enrolled between October 27, 2016, and September 9, 2018. Follow-up ended on December 3, 2020.InterventionsPatients were randomized to undergo either LPG-DTR or LTG.Main Outcomes and MeasuresThe primary co–end points were change in hemoglobin level and cumulative amount of vitamin B12 supplementation at 2 years after LPG-DTR or LTG. The secondary end points included morbidity, postoperative reflux esophagitis, quality of life, overall survival, and disease-free survival. Quality of life outcomes were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) 30-item core questionnaire (C30) and the EORTC QLQ stomach cancer–specific questionnaire at 3 months, 12 months, and 24 months.ResultsAmong 138 patients (mean [SD] age, 60.0 [10.9] years; 87 men [63.0%]; all of Asian race and Korean ethnicity), 68 (mean [SD] age, 56.7 [10.4] years; 39 men [57.4%]) were randomized to receive LPG-DTR and 69 (mean [SD] age, 61.3 [11.3] years; 48 men [69.6%]) were randomized to receive LTG. The mean (SD) changes in hemoglobin levels from baseline to month 24 were −5.6% (7.4%) in the LPG-DTR group and −6.9% (8.3%) in the LTG group, for an estimated difference of −1.3% (95% CI, −4.0% to 1.4%; P = .35). The mean (SD) cumulative amount of vitamin B12 supplementation was 0.4 (1.3) mg in the LPG-DTR group and 2.5 (3.0) mg in the LTG group, for an estimated difference of 2.1 mg (95% CI, 1.3-2.9 mg; P < .001). The late complication rates in the LPG-DTR and LTG groups were 17.6% and 10.1%, respectively (P = .31). The incidence of reflux esophagitis was not different between the LPG-DTR and LTG groups (2.9% vs 2.9%; P = .99). Compared with the LTG group, the LPG-DTR group had better physical functioning scores (85.2 [15.6] vs 79.9 [19.3]; P = .03) and social functioning scores (89.5 [17.9] vs 82.4 [19.4]; P = .03) on the EORTC QLQ-C30. Two-year overall survival (98.5% vs 100%; P = .33) and disease-free survival (98.5% vs 97.1%; P = .54) did not significantly differ between the LPG-DTR vs LTG groups.Conclusions and RelevanceIn this study, patients with upper-third early GC who received LPG-DTR required less vitamin B12 supplementation than those who received LTG, with no increase in complication rates and no difference in overall and disease-free survival rates. There was no difference in change in hemoglobin level between groups. In addition, the LPG-DTR group had better physical and social functioning than the LTG group. These findings suggest that LPG-DTR may be as safe as LTG and may be a function-preserving procedure for the treatment of patients with upper-third early GC.Trial RegistrationClinicalTrials.gov Identifier: NCT02892643

Food passage following proximal gastrectomy with double-tract reconstruction and its effect on nutritional status in early gastric cancer

“…Vitamin B12 and iron supplementation were required much less frequently following PG-DTR compared with that following conventional TG. [11,12,22] The present study also demonstrated that the levels of hemoglobin, vitamin B12, and iron were well preserved or recovered from the initial drop during the rst year after surgery. It was an expected result because patients who underwent PG were not deprived of intrinsic factors and gastric acid, which is critical in the absorption of vitamin B12 and iron, thanks to the remnant distal stomach.…”

Comparing the outcomes of laparoscopic proximal and laparoscopic total gastrectomy: A retrospective analysis of a single center in Japan

“…35,45 Recently, a randomized controlled trial comparing LPG with DT versus LTG was first reported. 46 Results showed that LPG was superior in reducing vitamin B12 supplementation, but there was no significant difference between LPG and LTG regarding postoperative body weight. In this study, only 60% of the food entered the remnant stomach after DT.…”

“…DT has been reported to improve food stagnation at the jejunal interposition; however, its nutritional benefits compared to TG remain unclear 35,45 . Recently, a randomized controlled trial comparing LPG with DT versus LTG was first reported 46 . Results showed that LPG was superior in reducing vitamin B12 supplementation, but there was no significant difference between LPG and LTG regarding postoperative body weight.…”

Prophylactic Abdominal Drainage After Gastrectomy: An Updated Meta-Analysis

“…In recent years, with the wide application of anastomotic instruments, the attention of perioperative management, and the progress of operation and anesthesia, the incidence of postoperative complications of gastric cancer has decreased signi cantly [21,22].The need for routine placement of abdominal drainage tube after gastric cancer operation for early detection of anastomotic leakage and intra-abdominal bleeding is no longer urgent.According to the results of the relevant prospective randomized controlled study, the intraoperative placement of abdominal drainage tube group did not signi cantly reduce the incidence of postoperative complications such as anastomotic leakage and intraabdominal bleeding [1,13].Therefore, they do not recommend the prophylactic placement of abdominal drainage tube during the operation of gastric cancer.Although the absence of abdominal drainage tube after radical resection of gastric cancer makes clinicians lack an intuitive indicator of postoperative bleeding or anastomotic leakage.…”