Abstract: Objective:To investigate the clinical efficacy of Later-cut overlap anastomosis versus Roux-en-Y anastomosis in laparoscopic total gastrectomy.
Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 1 804 patients with gastric cancer who underwent laparoscopic total gastrectomy in Fujian Medical University Union Hospital from January 2014 to March 2019 were collected. There were 1 346 males and 458 females, aged from 18 to 91 years, with a median age of 63 years. Of 1 804 patients, 100 undergoing Later-cut overlap anastomosis for digestive tract reconstruction in totally laparoscopic total gastrectomy and 1 704 undergoing Roux-en-Y anastomosis in laparoscopic-assisted total gastrectomy were allocated into modified group and traditional group, respectively. Observation indicators: (1) the propensity score matching conditions and comparison of general data between the two groups after propensity score matching; (2) intraoperative and postoperative situations; (3) complications; (4) follow-up, including ① functional scales of European Organization for Research and Treatment of Cancer quality of life questionnaire-core 30 (EORTC-QLQ-C30) for two groups after propensity score matching, ② symptom scales of EORTC-QLQ-C30 for two groups after propensity score matching, ③ symptom scales of European Organization for Research and Treatment of Cancer quality of life questionnaire of stomach 22 (EORTC-QLQ-STO22) for two groups after propensity score matching, ④ subgroup analysis; (5) learning curve of Later-cut overlap anastomosis. Patients were followed up by outpatient examination, paying a visit, Email and telephone interview once every 3 months within postoperative 2 years and once every 6 months within postoperative 3-5 years to detect postoperative life quality up to December 2019. The propensity score matching was conducted by 1∶1 matching using the nearest neighbor method. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Comparison of ordinal data between groups was analyzed using the nonparametric rank sum test. Measurement data with skewed distribution were represented as M (P25, P75) or M (range), and comparison between groups was done using the U test. The cumulative sum curve was used to analysis minor changes between individual and overall data, with the equation of CUSUM= （）,xi as esophagojejunostomy time of individuals, μ as the average time of esophagojejunostomy, n as serial number of patients.
Results:(1) The propensity score matching conditions and comparison of general data between the two groups after propensity score matching: 200 of 1 804 patients had successful matching, including 100 in the modified group and 100 in the traditional group respectively. Before propensity score matching, the gender (males or females), age, tumor diameter, cases with tumor located at upper, middle or total stomach (tumor location), cases with differentiated or undifferentiated tumor (tumor differentiation degree), level of preoperative Alb, cases in stage T1, T2, T3, T4a (T staging), cases in stage N0, N1, N2, N3 (N staging), cases in stage Ⅰ, Ⅱ, Ⅲ (Union International Control Cancer staging) were 62, 38, (55±13)years, 4.5 cm(1.5 cm, 7.5 cm), 22, 67, 11, 72, 28, (42±4)g/L, 36, 11, 39, 14, 58, 16, 8, 18, 44, 29, 27 of the modified group, versus 1 284, 420, (62±11)years, 6.5 cm(2.5 cm, 8.0 cm), 891, 675, 138, 1 392, 312, (39±7)g/L, 148, 200, 393, 963, 498, 517, 257, 432, 322, 604, 778 of the traditional group, showing significant differences in the above indicators between the two groups (x²=8.89, t=5.69, Z=2.75, x²=35.31, 5.80, t=3.91, Z=-9.97, -5.44, -5.41, P<0.05). After propensity score matching, the above indicators were 62, 38, (55±13)years, 4.0 cm(1.5 cm, 7.5 cm), 22, 67, 11, 82, 18, (42±4)g/L, 36, 11, 39, 14, 58, 16, 8, 18, 44, 29, 27 of the modified group, versus 68, 32, (56±11)years, 4.0 cm(1.5 cm, 7.4 cm), 12, 74, 14, 87, 13, (41±5)g/L, 23, 18, 45, 14, 54, 18, 10, 18, 42, 40, 18 of the traditional group, showing no significant difference in the above indicators between the two groups (x²=0.79, t=0.30, Z=0.87, x²=3.65, 0.95, t=1.49, Z=-0.94, 1.43, -0.50, P>0.05). (2) Intraoperative and postoperative situations: after propensity score matching, the operation time, volume of intraoperative blood loss, the number of lymph node dissected, time to the first flatus, time to fluid diet intake, duration of postoperative hospital stay, treatment expenses were (195±41)minutes, 72 mL(range, 5-125 mL), 44±15, (3.4±1.1)days, (4.1±1.3)days, (10.7±4.3)days, (74 299±20 102)yuan of the modified group, versus (192±78)minutes, 67 mL(range, 10-195 mL), 40±18, (3.7±1.2)days, (4.5±1.9)days, (14.0±9.2)days, (71 029±12 231)yuan of the the traditional group, respectively. There was no significant difference in the operation time, the number of lymph node dissected, time to the first flatus, time to fluid diet intake, or treatment expenses between the two groups (t=0.35, 1.73, 1.84, 1.74, 1.38, P>0.05). There were significant differences in the volume of intraoperative blood loss and duration of postoperative hospital stay between the two groups (Z=0.62, t=3.25, P<0.05). (3) Complications: three patients in the modified group had complications, including 2 cases of anastomotic leakage and 1 case of abdominal infection. Four patients in the traditional group had complications, including 2 cases of anastomotic leakage, 1 case of anastomotic hemorrhage, 1 case of abdominal infection. There was no significant difference in the complications between the two groups (x²=0.00, P>0.05). Patients with anastomotic leakage and abdominal infection were cured after conservative treatments including adequate drainage, nutritional support, anti-inflammation. Patients with anastomotic hemorrhage were cured after blood transfusion and hemostatic therapy. There was no perioperative death in either group. (4) Follow-up: 146 patients received life quality evaluation at postoperative 6 months, including 78 in the modified group and 68 in the traditional group. ① Functional scales of EORTC-QLQ-C30 for two groups after propensity score matching: the scores of overall health functioning, physical functioning, role functioning, cognitive functioning, emotional functioning, social functioning were 31(22,48), 75±27, 77±21, 79±15, 80±21, 76±29 for the modified group, respectively, versus 38(22,57), 77±30, 79±27, 82±30, 82±31, 78±30 for the traditional group, showing no significant difference between the two groups (Z=0.46, t=0.39, 0.40, 0.66, 0.49, P>0.05). ② Symptom scales of EORTC-QLQ-C30 for two groups after propensity score matching: the scores of fatigue, nausea and vomiting, pain, dyspnea, hyposomnia, anorexia, constipation, diarrhea, financial difficulty were 75±22, 89±19, 82±19, 77±19, 90±23, 74±14, 67±27, 74±28, 61±29 for the modified group, respectively, versus 72±28, 88±23, 91±23, 72±19, 88±19, 79±29, 68±28, 72±23, 61±24 for the traditional group; there was no significant difference in the scores of fatigue, nausea and vomiting, dyspnea, hyposomnia, anorexia, constipation, diarrhea or financial difficulty between the two groups (t=0.70, 0.26, 1.56, 0.49, 0.43, 0.20, 0.43, 0.09, P>0.05), while there was a significant difference in the score of pain (t=2.48, P<0.05). ③ Symptom scales of EORTC-QLQ-STO22 for two groups after propensity score matching: the scores of dysphagia, chest pain or abdominal pain, gastroesophageal reflux, eating disorder, anxiety, dryness of mouth, taste disorder, appearance disturbance, hair loss were 11(6, 20), 13(4, 22), 9(4, 21), 11(7, 20), 23(11, 34), 24(10, 31), 11(5, 21), 19(11, 35), 11(6, 25) for the modified group, respectively, versus 16 (7, 31), 14 (6, 22), 7(5, 16), 11(6, 20), 22 (13, 29), 28 (12, 33), 9 (5, 17), 20 (10, 25), 13 (5, 23) for the traditional group; there was no significant difference in the scores of chest pain or abdominal pain, gastroesophageal reflux, eating disorder, anxiety, dryness of mouth, taste disorder, appearance disturbance, hair loss between the two groups (Z=0.41, -0.01, 0.99, -0.03, 0.52, 0.46, -0.20, 0.44, P>0.05), while there was a significant difference in the score of dysphagia (Z=-2.07, P<0.05). ④ Subgroup analysis: after propensity score matching, cases with no, mild, moderate, severe pain (degree of pain perception) for pain-related items in EORTC-QLQ-C30 were 49, 24, 4, 1 of the modified group, versus 43, 9, 14, 2 of the traditional group, showing a significant difference between the two groups (Z=-2.519, P<0.05). (5)Learning curve of Later-cut overlap anastomosis. The cumulative sum curve for esophagojejunostomy time of the 100 patients in the modified group showed a inflection point at the 33th patient, so the 1st-33th patients were allocated into learning phase and the 34th-100th patients were allocated into stable phase. The operation time, anastomosis time, volume of intraoperative blood loss, the number of lymph node dissected, time to first flatus, time to postoperative liquid diet intake, duration of hospital stay, treatment expenses for patients in the learning phase were (216±60)minutes, (28±10)minutes, 70 mL(range, 10-204 mL), 41±17, (4.5± 0.9)days, (5.0±0.8)days, (11.1±4.3)days, 68 722 yuan(range, 52 312-94 943 yuan), respectively, versus (189±51)minutes, (23±8)minutes, 65 mL(range, 5-200 mL), 43±16, (4.4±1.0)days, (5.3±1.1)days, (10.6±6.8)days, 67 380 yuan(range, 49 289-92 732 yuan) for patients in the stable phase. There were significant differences in the operation time and anastomosis time between the two groups (t=2.27, 2.87, P<0.05). There was no significant difference in the volume of intraoperative blood loss, the number of lymph node dissected, time to first flatus, time to postoperative liquid diet intake, duration of hospital stay or treatment expenses between the two groups (Z=0.57, t=0.69, 0.49, 1.39, 0.39, Z=0.69, P>0.05).
Conclusion: Later-cut overlap anastomosis is a digestive tract reconstruction method after totally laparoscopic total gastrectomy, which can reduce the volume of intraoperative blood loss, relieve postoperative eating obstruction and pain and improve postoperative life quality of patients.