Analysis Of Esophageal Reflux After Proximal Gastrectomy Between Gastric Tube Reconstructionand Traditional Reconstruction

Adenocarcinoma of the esophagogastricj unction (AEG) is defined as an adenocarcinoma that liesbetween.5cm proximal and5cm distal tothe esophagogastfic junction (EGJ).AEG is divided into three types based on purely topographic anatomical criteria (Siewertclassification). TypeⅠ:adenocarcinoma of the distal esophagus, which usually arises from an area with specialized intestinal metaplasia of the esophagus and may infiltrate the EGJ from above1.0-5.0cm. Type II:true carcinoma of the cardia arising immediatelyat the EGJ (from1.0cm above the EGJ to2.0cm below the EGJ). Type III: subcardialgastric carcinoma that infiltratesthe EGJ and distal esophagus frombelow (about2.0～5.0cm below the EGJ).Recent epidemiological investigations have shown that the incidence of AEG is rising at an alarming rate, especially in the Western word.However, the Siewert type I and II are the main pathological types in western countries and the Siewert type Ⅲis the main pathological types. Therefore, the AEG has attracted more and more attention from the clinicians.According to two prospective clinical trials from Netherlands Dutch and Japan’s JCOG9502and several retrospective studies from severalwestern centers, tumor resection performedby transabdominalapproach is likely to be the main strategy for treatment oftype II and III AGE.Proximal gastrectomyisone of the most common surgical procedures, however, there are severalpostoperative complications. For example, the incidence of reflux esophagitis is20-35%and the gastroesophageal reflux symptoms can be up to60-70%, which seriously affects the lifequality of patients after surgery. Based on these observations, traditional gastroesophagostomyis further modified and gastric tube gastroesophagostomyis first reported in1998by Shiraishi. This method includes two steps:(1) after proximal gastrectomy, the residual lesser gastric curvatureis cut and the gastric tube is reconstructed.(2) Anastomosis shouldbe used between the gastric tube and esophagus.According to thepathogenesisof reflux esophagitis (RE), gastric acid is known as an important factor resulting in the reflux esophagitis. The gastric tube gastroesophagostomycan significantly reduce the residual gastric mucous membrane area and thus may reduce the gastric acid secretion and the incidence of reflux esophagitis theoretically. In addition, there are also some advantages for gastric tube gastroesophagostomysuch as simple operation, less surgical trauma, withoutadditional time andreservinga residual stomach and duodenal path. If thisis an effective method to prevent postoperative reflux esophagitis, gastric tube gastroesophagostomywould be a perfect technology for alimentary tract reconstruction after proximal gastrectomy. Therefore, the systematic evaluation for the effect of gastric tube in preventing reflux esophagitis after proximal gastrectomy andthe action mechanism will have important clinical significance.Objective:We aimed to systematically evaluate the effect of gastric tube gastroesophagostomy in preventing reflux esophagitis after proximal gastrectomy and explore the action mechanism, which may provide some references for personalized surgery of AEG patients.Methods:A total of55patients who underwent proximal gastrectomyat our department from January2011to January2012were selected to participate in this study. According to operation mode, the55patients were divided into routine group and gastric tube group. The general clinical data, Visick score of postoperative reflux symptoms, LA grading of postoperative reflux esophagitisatgastroscope, the residual stomach capacity,24-hour pH monitoring for esophagusand others were recorded for statistical analysis by the SPSS13.0soft. All measurement data were expressed as mean±standard deviation and difference was analyzed by T test. The countdata were analyzed by X2test. P<0.05was considered asstatistically significant difference.Results:There was no statistically significant difference between the gastric tube group and the routine group in gender and age distribution. For the postoperative pathological condition, there was also no statistically significant difference between two groups in the AEG Siewert type distribution, the pathological type, TNM staging, the infiltrated layers of stomach wall, and the lymphatic metastasis. No statistically significant differences between the gastric tube group and the routine group in operation duration (228±11min), intraoperative blood loss (134±56ml), and postoperative hospitalization days (7.4±0.8days) wereobserved. In the gastric tube group, there were2patients with anastomotic fistula and postoperative bleeding, one patient with dyskinesia of gastric, and they were all cured by conservative treatment. The Visisck score of postoperativereflux esophagitis in gastric tube group was as follow:grade I,19cases (73.1%), grade II,5cases (19.2%), grade III,2cases (7.7%), and grade IV,0cases (0.0%). For the gastric tube group, there were7patients with clinical symptoms of more thangrade Ⅱ (26.9%),2patients controlled by drug (7.7%.) and no serious patient with poorly controlled by drugs. For the routine group, there were27patients with clinical symptoms of more than grade Ⅱ (62.1%) and10patients controlled by drug (33.4%). Therefore, there was a statistically significant difference between two groups (P=0.043). Residual gastric capacity (267ml) of the gastric tube group was obviously less than that of the routine group (516ml). For the24-hour pH monitoring of postoperative esophagus, when the pH value less than4, there was a significant difference between the gastric tube group and the routinegroup in the total time (7.6%vs18.1%, P<0.05), the frequency ofreverse flow (95.3times vs302.3times, P<0.05) and the time ofreverse flow (4.7times per5minutes times vs15.1time per minutes, P<0.05).Conclusions:There is no significant statistical difference between the gastric tube gastroesophagostomyand the traditional gastroesophagostomy in the operation duration, intraoperative blooding loss, postoperative anastomotic leakage, the anastomotic bleeding and others. Compared to the routine group, the postoperative gastroesophageal reflux symptomsand the incidence of postoperative reflux esophagitisin the gastric tube groupisreduced significantly. Therefore, the gastric tube gastroesophagostomymay play a positive role in prevention of gastroesophageal reflux and other complications after proximal gastrectomy. In the gastric tube group, the small volume of residual gastric capacity and esophageal acid in24-hour pH monitoring of postoperative esophagussuggest that the reduction of gastric acid in the remnant stomach is an important mechanism forthe reduction of the incidence of gastroesophageal reflux and other complicationsafter the proximal gastrectomy..