Abstract: Objective:To investigate the clinical efficacy of jejunal interposed singletract and doubletract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG).
Methods:The prospective study was conducted. The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected. All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table, including patients using singletract jejunal interposition reconstruction in the singletract group and patients using doubletract jejunal interposition reconstruction in the doubletract group. Digestive tract reconstruction: after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum, singletract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma, and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the singletract group. Patients in the doubletract group used the same digestive tract reconstruction, but jejunum was not ligated. The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy. Observation indicators: (1) intra and postoperative situations; (2) followup situations. Followup using telephone interview was performed to detect postoperative complication, gastrointestinal function and body mass index (BMI) up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the nonparametric test. Repeated measurement data were analyzed by the repeated measures ANOVA. Comparisons of count data were done using chisquare test. Ordinal data were analyzed by the Kruskal Wallis H test.
Results:One hundred and eight patients were screened for eligibility, including 55 in the singletract group and 53 in the doubletract group. (1) Intra and postoperative situations: total operation time, digestive tract reconstruction time, volume of intraoperative blood loss, time to initial anal exsufflation, postoperative complications, cases with gastroesophageal reflux, intestinal obstruction and Visick grading > Ⅱ and duration of postoperative hospital stay were respectively (145±26)minutes, (30±6)minutes, (181±37)mL, (53±16)hours, 1, 1, 1, (10.0±2.4)days in the singletract group and (139±29)minutes, (26±3)minutes, (176±31)mL, (50±17)hours, 3, 0, 3, (9.4±1.4)days in the doubletract group, with no statistically significant difference between groups (t=0.725, 0.219, 0.162, -0.576, x²=2.960, 5.830, t=-0.993, P>0.05). Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks, and were improved by symptomatic treatment such as increasing the solid food intake. One patient in the singletract group had internal herniainduced intestinal obstruction and was cured by reoperation. There was no anastomotic leakage, bleeding, infection, dumping syndrome and gallstone between groups. Of 108 patients, 71 underwent 6cycle SOX chemotherapy, including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall. (2) Followup situations: 108 patients were followed up for 12.0-48.0 months, with a median time of 28.6 months. During the followup, bowel sound in the doubletract group and singletract group was 8 times / minute (range, 5-12 times / minute) and 3 times / minute (range, 2-5 times / minute), with a statistically significant difference between groups (Z=-0.692, P<0.05). The single food intake, serum gastrin level, ratio of serum pepsinogen I and Ⅱ levels and BMI from preoperation to postoperative 12 months were from (1 117±129)mL to (817±127)mL, from (12±5)pmol/L to (41±13)pmol/L, from 11.3±2.8 to 5.1±2.2, (65±7)kg to (63±5)kg in the singletract group and from (1 095±118)mL to (783±80)mL, from (10± 4)pmol/L to (40±10)pmol/L, from 12.4±2.9 to 4.2±1.3, from (63±6)kg to (58±6)kg in the doubletract group, respectively, with no statistically significant difference in single food intake, serum gastrin level and ratio of serum pepsinogen I and Ⅱ levels between groups (F=0.468, 0.108, 0.161, P>0.05). There was a statistically significant difference in changing trend of BMI between groups (F=24.930, P<0.05).
Conclusion:Jejunal interposed singletract and doubletract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don′t affect secretion function of gastric remnant, but there are frequent bowel sounds and obvious weight loss.