| Part Ⅰ:Proximal gastrectomy versus total gastrectomy for upper-third gastric cancer:A meta-analysisObjective:To compare the efficacy between total gastrectomy(TG)and proximal gastrectomy(PG)for upper-third gastric cancer.Methodology:PubMed,Embase and Cochrane library were used to select suitable researches comparing TG to PG for upper-third gastric cancer.Stata 15.0 was used for meta-analysis and outcome measures,including 5-year overall survival rate,intraoperative parameters,complication morbidities,as well as nutritional levels.Results:Ten research articles involving 1450 patients were analyzed retrospectively.Our study showed that there was no significant difference of 5-year overall survival rate(P=0.790).TG had longer operation time(P=0.001),greater number of retrieved lymph nodes(P=0.000)and larger amount of estimated blood loss(P=0.010).In postoperative complications aspect,it was indicated that there was no significant difference in occurrence of reflux symptoms(P=0.172)and anastomotic leakage(P=0.688)between two groups.However,TG was related to higher risks of ileus(P=0.010).Conversely,TG showed less anastomotic stricture than PG(P=0.004).Also,the level of serum albumin,hemoglobin,total protein,and cholesterol in the long-term follow-up of PG was relatively better than that of TG.Subgroup analysis:Heterogeneity of intraoperative blood loss was mainly existed in small sample subgroups.The open surgery subgroup,the pre-2010 literature subgroup and the big sample subgroup showed more anastomotic stenosis in the PG group.The pre-2010literature subgroup showed that the PG group had more reflux symptoms than the TG group.Conclusion:PG was equivalent to the long-term effect of TG.In addition,PG showed higher postoperative nutritional level,but there were more anastomotic strictures.Therefore,both proximal gastrectomy and total gastrectomy were optional methods for treatment of upper-third gastric cancer.Part Ⅱ:Comparative analysis of clinical efficacy of proximal gastrectomy and total gastrectomy for Siewert Ⅱ/Ⅲ esophagogastric junction adenocarcinomaObjective:To compare the short and long-term efficacy,postoperative nutritional status and quality of life of patients with Siewert Ⅱ/Ⅲ esophagogastric junction adenocarcinoma treated with proximal gastrectomy and total gastrectomy,and to explore the best surgical procedure.Methods:We retrospectively reviewed 101 patients who underwent proximal gastrectomy(PG)or total gastrectomy(TG)for Siewert Ⅱ/Ⅲ esophagogastric junction adenocarcinoma(AEG)at General Surgery Department and Thoracic Surgery Department of Tianjin Medical University General Hospital from November 2014 to June 2018.The patients were divided into two groups according to the surgical methods:44 patients underwent PG and 57 patients underwent TG.In the PG group,8 patients underwent abdominal operation,including 6 cases underwent laparoscopic surgery and2 cases underwent open surgery,while 36 underwent transthoracic approach.In the TG group,34 patients underwent laparoscopic surgery and 23 underwent open surgery.In the PG group,28 cases were treated with tubular anastomosis,16 cases with esophagogastric anastomosis and pyloroplasty.Clinicopathologic characteristics and surgical outcomes of these two groups were compared.Results:In the PG group,there were 31 patients with Siewert Ⅱ and 13 patients with Siewert Ⅲ.In the TG group,there were 20 patients with Siewert Ⅱ and 37 patients with Siewert Ⅲ.There was significant difference in Siewert classification between the two groups(P=0.000).(1)There were no statistical differences in gender,age,BMI,ASA classification and past medical history between the two groups(P>0.05).(2)PG group had shorter operation time than TG group(258.2±68.9min vs 312.1±93min,P=0.002).The amount of intraoperative blood loss was comparable(P=0.072).(3)For postoperative rehabilitation,both groups had comparable time of first flatus,time of first intake of liquid diet and the postoperative hospital stay(P>0.05).And There was no significant difference in the postoperative complications of Clavien-Dindo(P>0.05).(4)Pathological results showed that the number of lymph node dissection in PG group was lower than that in TG group(20.4±7.2 vs 29.6±14.5,P=0.000)and tumor diameter in PG group was smaller than that in TG group(4.0±2.1cm vs 5.6±3.5cm,P=0.012).In addition,the depth of tumor in PG group was lower than that in TG group(χ~2=5.755,P=0.016)and as well as the TNM staging(χ~2=6.258,P=0.044).However,there were no statistical differences in the degree of tumor differentiation,Lauren classification and the number of metastasis lymph nodes between the two groups(P>0.05).(5)For survival,the follow-up period ranged from 1-50 months.There was no significant difference in survival curves between the two groups(χ~2=0.005,P=0.944).There was no significant difference in survival curves between the advanced patients from the two groups(χ~2=0.105,P=0.746).In the PG group,29 patients underwent chemotherapy,11 patients didn’t undergo chemotherapy and 4 patients failed to follow-up.In the TG group,36 patients underwent chemotherapy,14 patients didn’t undergo chemotherapy and 7 patients failed to follow-up.There was no significant difference in administration of chemotherapy between the two groups(χ~2=0.154,P=0.926)(6)Postoperative nutritional status:There was no significant difference in body weight changes and serum albumin between the two groups at 6 months and 1 year after surgery.Hemoglobin was significantly higher in the PG group than in the TG group at 1 year after surgery(118±13.8g/L vs 110.4±13.7g/L,P<0.05).(7)For quality of life,the PG group scored the same scores as the TG group on the functional subscale and overall health scale of QOL-C30 questionnaire(P>0.05).However,in the symptom subscale,PG group scored higher in nausea and vomiting(51.6±14.9 vs 44±15.9,P=0.043).Conclusions:1.For Siewert Ⅱ/Ⅲ esophagogastric junction adenocarcinoma,although proximal gastrectomy had no significant difference in survival time and postoperative complications from total gastrectomy,it had the advantages of short operation time and high postoperative hemoglobin level.However,it is recommended that the method is only applied to patients with smaller tumors and earlier TNM staging.2.For Siewert Ⅱ/Ⅲ esophagogastric adenocarcinoma,both proximal gastrectomy and total gastrectomy should be further validated in a prospective randomized controlled trial to determine which method is better to be selected in certain conditions. |
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