Application Of Modified Double Tracks Anastomosis In Radical Surgery Of Adenocarcinoma Of Esophagogastric Junction

Objective: In recent years, the incidence of adenocarcinoma ofesophagogastric junction has increased, R0resection is still the most effectivetreatment measures. However, on the basis of ensuring adequate resectionmargin, there is a controversy of adenocarcinoma of esophagogastric junctionfor proximal gastrectomy or total gastrectomy. Traditionally, the majority ofscholars are familiar with the application of direct anastomosis between thegastric remnant and esophagus, which is simple and quick,and the digestivetract reconstruction meet the physiological. However, induction of backflowesophagitis is inevitable, which seriously reduces the quality of patients' lives,and there is a possibility of recurrence in remnant stomach. Our previousstudies have shown that using modified double tracks anastomosis of our owndesign can reduce the occurrence of reflux esophagitis and significantlyimprove the quality of life than esophageal-remnant stomach end to sideanastomosis after radical proximal gastrectomy. Our study on the basis ofpreliminary studies, retrospective analysis of the cases of clinical data ofadenocarcinoma of esophagogastric junction underwent radical proximalgastrectomy or total gastrectomy and postoperative follow-up,aim at exploringthe status of the modified double tracks anastomosis in adenocarcinoma ofesophagogastric junction. Further, to prove the effect of anti-flow of modifieddouble tracks anastomosis and the effect of radical degree and prognosis ofproximal gastrectomy is non-inferiority of the total gastrectomy.to provide theobjective basis of the theoretical and clinical for the options of reasonablesurgical of adenocarcinoma of esophagogastric junction.Materials and Methods: Select clinical data of763cases ofadenocarcinoma of esophagogastric junction who underwent radical surgerytransabdominal from January2004to December2008in The Fourth Hospital of Hebei Medical University. According to the difference of extent of surgicalresection and digestive reconstruction technique, divided into the followingthree groups:Group A:modified double tracks anastomosis in radical proximalgastrectomy(266cases,213cases of male and53cases of women), GroupB:esophagus-remnant stomach direct anastomosis in radical proximalgastrectomy(252cases,204cases of male and48cases of females), Group C:Roux-en-Y esophagojejunostomy in radical total gastrectomy(245cases,198cases of male and47cases females). Among the three groups, the compositionof the basic features of the data are similar (such as number, gender, age, etc),to ensure the balance of the non-research factors, on this basis, using theComparative study. In this study, Group A, as experimental group, respectively,compared with the two groups (B and C), observe the effect of anti-reflux,radical cure, postoperative nutrition indicators, the3-year postoperativesurvival rates and other aspects of difference. The clinical evaluation index isas follows:1Information of clinical surgery (1)operation time,(2)No.5,6lymphnode metastasis,(3)postoperative complication,(4)positive rate of the stump.2Detection of nutrition index (1)nutrition indicators of blood (Hb, TP,ALB) in the preoperative, postoperative1week and6months,(2) prognosticnutritional index(PNI), PNI=10×serum albumin (ALB:g/dL)+0.005×totallymphocyte count (/mm3),(3) body weight.3Index of evaluate quality of life (1)gastroesophageal refluxgrade(Visick score),(2)grade standards of reflux symptoms in endoscopic(Los-AnGeles, LA),(3)percentage of food intake recovery, meals,(4)gastrointestinal symptom score(GSRS).4Prognosis and follow-up (1)remnant stomach and anastomotic stoma inpostoperative,(2)3-year survival rates, etc.Research indicators were analyzed by using SPSS17.0statistical software,A value of P <0.05was considered to be statistically significant.Results:1Operation time:in Group A was201±46minutes,in Group B was 171±35minutes,in Group C was177min±30minutes,the operation time ofGroup A was slightly longer than the other two groups (P <0.05).2The incidence of postoperative complications: in group A was8.65%(23/266), in Group B was8.33%(21/252), and in Group C was7.76%(19/245). Among the three groups, there were no significant differencein the incidence of postoperative complications (P＞0.05).3The positive rate of up stump: in Group A was1.50%(4/266), in Group Bwas1.98%(5/252), in Group C was2.45%(6/245). The positive rate of downstump: in Group A was1.12%(3/266),in Group B was1.19%(3/252),in GroupC was0.82%(2/245).There was no significant difference in the degree oftumor radical cure between proximal gastrectomy and total gastrectomy(P＞0.05).4The rate of No.5lymph node metastasis: in Group A was7.41%(4/54), inGroup B was14.58%(7/48), in Group C was18.63%(19/102).The rate of No.6lymph node metastasis: in Group A was6.72%(8/119), in Group B was3.53%(3/85), in Group C was12.32%(25/203). Compared with group A and B,the rate of lymph node metastasis was higher in Group C, however, there wasno significant difference (P＞0.05).5Nutrition indicators5.1Comparison with Group A and B: Group A: the value of Hb, ALB, TP, PNIreturned to the preoperative level in6months after surgery(P＞0.05), bodyweight closed to the preoperative level. Group B:6months after surgery, theHb value was still less than that of preoperative (P<0.05). Compared withpreoperative, there was no significant difference in the value of ALB, TP,PNI(P＞0.05), but the body weight was still lower than the preoperative level.6months after surgery, Hb value in Group A reached the preoperative level,However, in Group B, had not reached to the preoperative level, two groupswere significantly different (P<0.05). Body weight gain in Group A was higercompared with that of Group B after6months (P<0.05).5.2Comparison with Group A and C: Group C: the Hb value, did not regainpreoperative levels until the sixth postoperative month (P<0.05). the levels of PNI, ALP, and TP increased again and showed no difference from preoperativelevels(P＞0.05).6months after operation, the body weight did not regainpreoperative levels.6months after operation, in Group A, the levels of Hb,showed no difference from preoperative levels. In contrast, in Group C, thelevels of Hb, was significantly lower than preoperative levels, there was asignificant difference between Groups A and C (P<0.05).6months afteroperation, in Group A, body weight recovered to a higer level than Group B(P<0.05).6Evaluate the quality of life1year after operation6.1Visick grades(Ⅰ-Ⅳ)In each group:In Group A were89.85％(239/266),9.02％(24/266),1.13％(3/266),0％. In Group B were6.75％(17/252),73.81％(186/252),15.47％(39/252),3.97％(10/252). In Group C were83.27％(204/245),14.29％(35/245),1.63％(4/245),0.81％(2/245). The patient'squality of life was significantly different between Groups A and B, Groups Acould prevent the genesis of reflux esophagitis better (P<0.05). There was nosignificant difference between Group A and Group C(P＞0.05).6.2Esophageal reflux LA grades(A-D) in endoscopic:In Group A were88.52％(54/61),8.20％(5/61),3.28％(2/61),0％. In Group B were12.70％(8/63),69.84％(44/63),17.46％(11/63),0％. In Group C were74.36％(29/39),20.51％(8/39),5.13％(2/39),0％. The patient's quality of life was significantlydifferent between Groups A and B, Groups A could prevent the genesis ofreflux esophagitis better (P<0.05). There was no significant differencebetween Group A and Group C(P＞0.05).7Remnant stomach and anastomotic stomaAnastomotic recurrence rate of anastomotic stoma in each group:InGroup A was2.63％(7/266), in Group B was1.98％(5/252), in Group C was1.63％(4/245).recurrence rate of remnant stomach:In Group A was0.75％(2/266), in Group B was1.19％(3/252). Recurrence rate of anastomotic stomaamong the three groups, there were no significant difference(P＞0.05).Recurrence rate of remnant stomach was no significant difference betweenGroup A and Group B (P＞0.05). 8Overall3-year survival rate687cases were recorded by follow-up, in Group A there were235cases,in Group B there were224cases, in Group C there were228cases. Overall3-year survival rate:in Group A was62.98％(148/235), in Group B was57.46％(131/228),in Group C was65.18％(146/224).Between Group A and GroupC, there was no significant difference in overall3-year survival rate (χ2=0.241,P=0.623). Between Group A and Group C, there was no significant differencein overall3-year survival rate (χ2=1.474, P=0.225)Conclusions:1Modified double tracks anastomosis is a better alimentary canalreconstructive method for radical proximal gastrectomy than esophagus-remnant stomach direct anastomosis, because it alleviated reflux symptomsand improved the quality of patients' lives after operation.2Between modified double tracks anastomosis and Roux-en-Yesophagojejunostomy, there is no significant difference in the tumor radicaldegree. Additionally, with blocking the output segment of the jejunum in thisreconstruction, food in-flux into the duodenum is enabled, which is consistentwith physiological functions.3The overall3-year survival rate is not significantly different betweenproximal gastrectomy and total gastrectomy.Modified double tracks anastomosis can ensure the tumor radical andimprove the quality of life, is safe and feasible. Therefore, it is a betteralimentary canal reconstructive method for adenocarcinoma of esophago-gastric junction after radical proximal gastrectomy.