Proximal gastrectomy with tubular stomach reconstruction vs total gastrectomy for proximal gastric cancer following neoadjuvant chemotherapy: A multicenter retrospective study.

Abstract

Background: Gastric cancer (GC) is a major global health challenge, and the treatment of proximal GC in particular presents unique clinical and surgical complexities. Currently, there is no consensus on whether proximal gastrectomy (PG) or total gastrectomy (TG) should be used for advanced proximal GC, and the choice of postoperative gastrointestinal reconstruction method remains controversial.

Aim: To compare the short-term efficacy, long-term survival, and postoperative reflux outcomes of PG with tubular stomach reconstruction vs TG with Roux-en-Y reconstruction in patients with proximal GC following neoadjuvant chemotherapy (NACT) in an effort to provide valuable insights for clinical decision-making regarding the optimal surgical approach.

Methods: A multicenter retrospective cohort study was conducted at two Chinese medical centers between December, 2012 and December, 2022. Patients with histologically confirmed proximal GC who received NACT followed by either PG with tubular stomach reconstruction or TG with Roux-en-Y reconstruction were included. Propensity score matching (PSM) was performed to balance baseline characteristics, and the primary endpoint was 5-year overall survival (OS). Secondary endpoints included recurrence-free survival (RFS), postoperative complications, and reflux severity.

Results: After PSM, 244 patients (122 PG, 122 TG) were finally included and all baseline characteristics were comparable between groups. The PG group had a significantly shorter operation time compared to the TG group (189.50 vs 215.00 minutes, P < 0.001), with no differences in intraoperative blood loss or postoperative complications (19.68% vs 14.75%, P = 0.792). The 5-year OS rates were 52.7% vs 45.5% (P = 0.330), and 5-year RFS rates were 54.3% vs 47.6% (P = 0.356) for the PG and TG groups, respectively. Reflux symptoms (18.0% vs 31.1%, P = 0.017) and clinically significant reflux based on gastroesophageal reflux disease questionnaire scores ≥ 8 (7.4% vs 21.3%, P < 0.001) were significantly less frequent in the PG group. Multivariate analysis identified histological differentiation (HR = 2.98, 95%CI: 2.03-4.36, P < 0.001) and tumor size (HR = 0.26, 95%CI: 0.17-0.41 for tumors ≤ 4 cm, P < 0.001) as independent prognostic factors.

Conclusion: PG with tubular stomach reconstruction is comparable to TG in terms of surgical safety and long-term oncological outcomes for proximal GC patients following NACT. Additionally, PG has the advantages of shorter operation time and lower rates of postoperative reflux, suggesting potential benefits for patient quality of life. Notably, the analysis of postoperative prognostic factors, including histological differentiation and tumor size, further informs clinical decision-making and highlights the importance of individualized treatment strategies.