[Comparison of quality-of-life after proximal gastrectomy with double tract reconstruction versus gastric tube reconstruction in patients with proximal gastric cancer].

Objective: To compare the surgical safety and postoperative quality of life between proximal gastrectomy with double tract reconstruction (PG-DT) and proximal gastrectomy with gastric tube reconstruction (PG-GT) for proximal gastric cancer. Methods: This was a retrospective cohort study of clinical and follow-up data of 99 patients with proximal gastric cancer who had undergone double tract or gastric tube surgery in Nanjing Drum Tower Hospital from January 2016 to September 2021. We allocated them to two groups according to surgical procedure, namely a double tract group (PG-DT, 50 patients) and gastric tube group (PG-GT, 49 patients). Proximal gastrectomy with double tract reconstruction entails constructing a Roux-en-Y esophagojejunostomy after severing the proximal stomach, and then constructing a side-to-side anastomosis between the residual stomach and the jejunum to establish an anti-reflux barrier and thus minimize postoperative gastroesophageal reflux. Proximal gastrectomy with gastric tube reconstruction entails severing the proximal gastric stomach, constructing a tubular shaped gastric remnant, and then using a linear stapler to directly anastomose the posterior wall of the esophagus to the anterior wall of the resultant gastric tube. The primary end point was the quality of life of the two groups 1 year postoperatively (post-gastrectomy syndrome assessment scale: the higher the scores for change in body mass, food intake per meal, meal quality subscale, total physical health measurement, and total mental health measurement, the better the quality-of-life, and the higher the scores for other indicators, the worse the quality-of-life). The secondary end points were intraoperative and postoperative status, changes in nutritional status 1, 3, 6, and 12 months postoperatively, and long-term postoperative complications (gastroesophageal reflux, anastomotic stenosis, intestinal obstruction, and gastric emptying disorder 1 year postoperatively). Results: In the PG-DT group, there were 35 (70%) men and 15 (30%) women, 33 (66.0%) patients were aged <65 years, and 37 (74.0%) of them had a body mass index of 18-25 kg/m2; whereas in the PG-GT group, there were 41 (83.7%) men and eight (16.3%) women, 21 (42.9%) patients aged <65 years, and 34 (69.4%) patients with a body mass index of 18-25 kg/m2. There were no significant differences in baseline data between the two groups except for age (P=0.021). There were no significant differences in intraoperative blood loss, number of lymph node dissected, length of hospital stay, and incidence of perioperative complications between the two groups (all P>0.05). Compared with the PG-GT group, the incidence and severity of postoperative reflux esophagitis were significantly lower in the PG-DT group (4.0% [2/50] vs. 26.5% [13/49], χ2=13.507, P=0.009). The incidences of postoperative anastomotic stenosis, intestinal obstruction, and gastric retention did not differ significantly between the two groups (all P>0.05). Patients in the PG-DT group had better quality-of-life scores for esophageal reflux (2.8 [2.3,4.0] vs. 4.8 [3.8,5.0], Z=3.489, P<0.001), eating discomfort (2.7 [1.7,3.0] vs. 3.3 [2.7,4.0 ], Z=3.393, P=0.001), and total symptoms (2.3 [1.7,2.7] vs. 2.5 [2.2,2.9], Z=2.243, P=0.025) than those in the gastric tube group; The scores for postoperative symptoms (2.0 [1.0,3.0] vs. 2.0 [2.0, 3.0], Z=2.127, P=0.033), meals consumed (2.0 [1.0, 2.0] vs. 2.0 [2.0, 3.0], Z=3.976, P<0.001), work (1.0 [1.0, 2.0] vs. 2.0 [1.0, 2.0], Z=2.279, P=0.023] and daily life (1.7 [1.3, 2.0] vs. 2.0 [2.0, 2.3], Z=3.950, P<0.001) were better in the PG-DT than the PG-GT group. Patients in the PG-GT group scored better than those in the PG-DT group for somatic symptoms, such as anal evacuation (3.0 [2.0, 4.0] vs. 3.5 [2.0, 5.0], Z=2.345, P=0.019). There were no significant differences in hemoglobin, serum albumin, serum total protein, or weight loss 1 year postoperatively between the two groups (all P>0.05). Conclusions: The safety of double tract anastomosis for proximal gastric cancer is comparable to that of gastric tube surgery. Compared with gastric tube surgery, double tract anastomosis achieves less esophageal reflux and better quality of life, making it a preferable surgical procedure for proximal gastric cancer.目的： 对行近端胃切除双通道吻合与近端胃切除管型胃食管吻合的手术安全性和术后生活质量进行比较。 方法： 本研究采用回顾性队列研究方法，纳入南京大学附属鼓楼医院2016年1月至2021年9月期间收治的99例行近端胃切除术的近端胃癌患者的临床及随访资料。根据吻合方式的不同，分为双通道吻合组（50例）与管型胃食管吻合组（49例）。其中双通道吻合是在离断近端胃后，行食管空肠Roux-en-Y吻合，再在残胃与空肠之间侧侧吻合，建立抗反流屏障从而减少术后胃食管反流；而管型胃吻合是在离断近端胃后，远端残胃行管型胃塑形，使用直线吻合器在食管后壁与胃管前壁之间直接吻合。主要观察指标为两组患者术后1年生活质量，评价标准参考胃切除术后综合征评估量表；体质量变化、每餐摄入的食物量、用餐质量分量表和躯体健康及心理健康总测量项目分数越高，表示情况越好，其余指标均为分数越高，表示情况越差；次要观察指标为术中术后情况、术后远期并发症的发生情况和术后1、3、6和12个月的营养状况变化。 结果： 双通道吻合组男性35例（70%），女性15例（30%），<65岁者33例（66.0%），体质指数18~25 kg/m2者37例（74.0%）；管型胃食管吻合组男性41例（83.7%），女性8例（16.3%），<65岁者21例（42.9%），体质指数18~25 kg/m2者34例（69.4%）。除年龄外（P=0.021），两组患者基线资料差异无统计学意义（均P>0.05）。两组术中出血量、淋巴结清扫数目、住院时间和围手术期并发症发生率比较，差异无统计学意义（均P>0.05）。术后1年时，与管型胃食管吻合组比较，双通道吻合组反流性食管炎发生率更低［4.0%（2/50）比26.4%（13/49），χ2=13.507，P=0.009］，但在吻合口狭窄、肠梗阻和胃排空障碍方面，两组的差异无统计学意义（均P>0.05）。双通道吻合组患者在食管反流［2.8（2.3，4.0）分比4.8（3.8，5.0）分，Z=3.489，P<0.001］、进食不适［2.7（1.7，3.0）分比3.3（2.7，4.0）分，Z=3.393，P=0.001］、总症状［2.3（1.7，2.7）分比2.5（2.2，2.9）分，Z=2.243，P=0.025］等方面的生活质量评分均优于管型胃食管吻合组；双通道吻合组患者在术后症状［2.0（1.0，3.0）分比2.0（2.0，3.0）分，Z=2.127，P=0.033］、用餐［2.0（1.0，2.0）分比2.0（2.0，3.0）分，Z=3.976，P<0.001］、工作［1.0（1.0，2.0）分比2.0（1.0，2.0）分，Z=2.279，P=0.023］和日常生活［1.7（1.3，2.0）分比2.0（2.0，2.3）分，Z=3.950，P<0.001］等方面评分优于管型胃食管吻合组。管型胃食管吻合组患者在肛门排气［3.0（2.0，4.0）分比3.5（2.0，5.0）分，Z=2.345，P=0.019］方面评分优于双通道吻合组。两组患者术后血红蛋白、血清白蛋白和血清总蛋白水平以及术后1年体质量下降率比较，差异均无统计学意义（均P>0.05）。 结论： 近端胃癌行双通道吻合手术的安全性与管型胃手术相当。与管型胃手术相比，双通道吻合术后患者食管反流更少，生活质量更好，是近端胃癌较为理想的手术方式之一。.