1. Brief Review on Proximal Gastrectomy for
Early Gastric Cancer
General Surgery I.C. : Dr. Lei Keng Sun
Tutor : Dr. Ng Wai Lon
Date: 28th April,2023

2. Hx of Proximal Gastrectomy
(Tetsuo Maki 1908-2006)
Tohoku University, Japan
(Tsuneo Shiratori 1922-2012)
Nara Medical University, Japan
• Tetsuo Maki published an surgical procedure, “Pylorus preserving
gastrectomy,” in 1967.
• Reduce dumping syndrome, postgastrectomy gallstone, and digestive
function disturbances after distal gastrectomy for benign ulcer.
• Tsuneo Shiratori expanded the indication for gastric cancer in 1991.
Sung HN, Woo JY Surgery for Gastric Cancer 2019

3. Hx of Proximal Gastrectomy
Over the past 30 years, the prevalence of upper third GC and EGJ
cancer has increased.
Standard surgical treatment:
Total gastrectomy with D2 lymph node dissection  T2 or higher
upper third GC and GEJ cancers
TG post-gastrectomy syndrome (5–50%)
Weight loss, Dumping syndrome, and Anemia.

4. Hx of Proximal Gastrectomy
Proximal gastrectomy (PG)
Simple esophagogastrostomy after PG is the simplest and most convenient
physiological reconstruction method.
Without additional anti-reflux treatment
Several retrospective studies of esophagogastrostomy have observed
Early complications 3.1-24%
Stenosis 0-52.2 %
Reflux esophagitis 20-65.2%
Residual food 21.8%
Souya Nunobe, et la. Current status of proximal gastrectomy for gastric and esophagogastric
junctional cancer: A review . Japan, Ann Gastroenterol Surg. 2020;4:498–504

5. Hx of Proximal Gastrectomy
In recent years, anti-reflux reconstruction techniques:
Double flap technique / Double-tract reconstruction
↓Postoperative reflux esophagitis
↓postoperative weight loss and prevent anemia.
Prospective studies are underway to determine whether PG with anti-
reflux techniques improves patient-reported quality of life.

6. Aim
Reviewed available evidence for the use
of Proximal Gastrectomy (PG) for upper
third Gastric Cancer
1. Which patients are oncologically appropriated for PG?
2. Various types of reconstruction can be perfromed after PG?
3. Benefits on PG vs TG

7. UICC TNM categories and
stage grouping: Stomach
T- Primary tumour
Tis Carcinoma in situ: intraepithelial tumor without invasion of
the lamina propria, high-grade dysplasia
T1: T1a lamina propria or muscularis mucosae
T1b submucosa
T2: muscularis propria
T3: subserosa
T4: perforates serosa (visceral peritoneum)
T4a perforates serosa
T4b invades adjacent structures
N – Regional Lymph
Nodes
N1: 1 to 2 regional LNs
N2: 3 to 6 regional LNs
N3 : 7 or more regional LNs
N3a: 7 to 15 regional LNs
N3b: 16 or more regional LNs
M – Distant Metastasis
M0: No distant metastasis
M1: Distant metastasis

8. TNM categories and stage grouping
based on the 15th edition of
Japanese Classification of Gastric
Carcinoma which identical to UICC
8th edition
Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition)

9. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition )
Algorithm of Standard Treatments to be Recommended in Clinical Practice

10. The standard surgery for gastric cancer
Gastrectomy
with adequate
margins
Perigastric and
extragastric LN
dissection
Consequent
gastrointestinal
reconstruction

11. Principle of Adequate Margins
KGCA = Korean Gastric Cancer Association; JGCA = Japanese Gastric Cancer Association;
CSCO = Chinese Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; ESMO = European Society for Medical
Oncology;
≥2 cm for T1 tumors (JGCA )
≥3 cm proximal margin in T2 / deeper tumors with
Borrmann type I and II tumors. (JGCA, CSCO)
A 5 cm proximal margin with Borrmann types III and IV.
(JGCA, CSCO)
5 cm for Stage IB-III gastric cancer. (KGCA, NCCN,
ESMO)
8 cm for diffuse cancer when DG, otherwise, total
gastrectomy was recommended. (ESMO)
Borramann Classification

12. Lymph node dissection

13. Indiacations for Function-Preserving Surgery
Eom SS, A Comprehensive and Comparative Review of Global Gastric Cancer Treatment Guidelines. J Gastric Cancer. 2022 Mar;22(1):323

14. Siewert Type III Siewert Type II
AJCC

15. • Initially suggested by the JGCA
• Definition of D levels (Recently D1, D1+, D2)
D1: Nos 1-7.
D1+: D1 + Nos.8a, 9, 11p.
D2: D1 + Nos.8a, 9, 11p, 11d, 12a.
• The indications for different LND ranges are
heterogeneous, according to each guideline.
• In Principle:
D1 / D1+  cT1N0
D2  cN+ / ≥cT2 tumor / LN cannot be dismissed.
Lymph node dissecton

16. Oncologically appropriated patient selection
for
Proximal Gastrectomy
• Stage : Stage Ia, (cT1a /1bN0) early gastric cancer
Contraindication for ESD
• Location : Upper third of the stomach
≥ 50% of the distal gastrectomy preserved
Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition )

17. Lymph node dissection
Prximal gastrectomy vs Total gastroectomy
D1 : Nos. 1, 2, 3a, 4sa, 4sb, 7
D1+: D1 + Nos. 8a, 9, 11p
D2 : D1 + Nos. 8a, 9, 11p, 11d
Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition )
D1 : Nos. 1 - 7
D1+: D1 + Nos. 8a, 9, 11p
D2 : D1 + Nos. 8a, 9, 11p, 11d, 12a
For tumors invading the esophagus, Nos. 19, 20, and 110 should additionally be dissected in D2
Nos. 19 Infradiaphragmatic LNs along subphrenic artery Nos. 20 paraesophageal LNs in diaphragmatic hiatus
Nos. 110 lower thoracic para-esophageal LNs

18. Post-OP complication rate:
PG TG
10.9%
16.9%
The incidence of Los
Angeles grade C, D Severe
reflux esophagitis
Higher
:
Jan-2001 to Dec-2008
170 patients ( 64 PG, 106 TG)

19. Post-OP complication rate:
PG TG
10.9%
16.9%
The incidence of Los
Angeles grade C, D Severe
reflux esophagitis
Higher
:
Hb, Pro, vit B12 (2,3,5 ys) : Higher
Body weight (2,3,5 ys) :
loss
Albumin 3, 5ys : lower

20. Post-OP complication rate:
PG TG
10.9%
16.9%
The incidence of Los
Angeles grade C, D Severe
reflux esophagitis
Higher
:
Hb, Pro, vit B12 (2,3,5 ys) : Higher
Body weight (2,3,5 ys) :
loss
Albumin 3, 5ys : lower
5-year OS rate no significant differencec
Jan-2001 to Dec-2008
170 patients ( 64 PG, 106 TG)

21. significantly higher in PG group respect to

22. May be for these reasons, PG is not commonly performed in Western Countries

23. Reconstruction after PG
Esophagogastric anastomosis
• Simple esophagogastrostomy
• Tube-like stomach
esophagastrostomy
• Side overlap with fundiplication by
Yamashita (SOFY)
• Double-flap technique
Reconstruction uses small
intestine
• Double-tract method
• Jejunal interposition
• Jejunal pouch interposititon

24. Simple esophagogastrostomy without
additional anti-reflux treatment, hight
incidence of postoperative reflux esophagitis
20-65%
26 studies, enroll 1439 case
Prospective case series:1
Randomized controlled trial: 1
Retrospective case series: 24

25. Yuki Hirata, et la. The role of proximal gastrectomy in gastric cancer. Chin Clin Oncol 2022;
Trend to
Reconstruction
after PG

26. Double-Tract
reconstruction
1. Roux-en Y esophagojejunostomy,
2. Gastrjejunostomy 15 cm below the
esophagojejunostomy
3. And jejunojejunostomy 25-30cm below
the gastrojejunostomy
This method maintains the continuity of the
jejunum, making it easier to perform the procedure.

27. Double-Flap Valvuloplastic Esophagogastrostomy
(a) 工-shaped seromuscular
double flap.
(b) Suturing of the
esophagus and the
gastric mucosal window.
(c) Esophagogastrostomy
covering with the double
flap.
A. The esophagogastrostomy of the
posterior wall.
B. Continous suture were used for
layer-layer suturing on the closure
of anterior wall.
C. Anastomosis was covered by
seromuscular flaps.
D. The view of completed anastomosis
with the double flaps.
Lap-PG with double-flap (Yoshihiro Saeki, 2018)

28. Saze et al. BMC Surg (2021) 21:392
https://doi.org/10.1186/s12893-021-01390-
1
2005-2020
Enrolled 69 pts

29. Thus, 76 patient were included in this study.

30. Comparing esophagogastrostomy (CS and DF) and DT showed that esophagogastrostomy could
significantly preserve both subcutaneous and visceral adipose tissues (P < 0.001 and P 1⁄4 0.04,
respectively).

31. Conclusion: DF is a relatively
better reconstruction method
for preserving fat mass and
preventing reflux among the
three common reconstruction
methods.

32. Postoperative QoL
Karanicolas PJ, Graham D, Gönen M, et al. Quality of life after gastrectomy for
adenocarcinoma: a prospective cohort study. Ann Surg 2013
• Enrolled 134 ( TG, DG, PG)
• PG was direct EG without specific anti-reflux procedures, more frequently reported reflux
esophagitis, nausea/vomiting, and global QoL impairment than did patients who
underwent DG or TG,
• The authors concluded that PG with direct EG should be avoided.

33. Postoperative QoL
Park JY, et al. Comparison of laparoscopic proximal gastrectomy with double-tract
reconstruction and laparoscopic total gastrectomy in terms of nutritional status or
quality of life in early gastric cancer patients. Eur J Surg Oncol 2018,
• Compared postoperative QOL between patients who underwent laparoscopic TG and
those who underwent laparoscopic PG followed by DTR in 80 GC patients, using QLQ-C30
and QLQ-STO22 administered longitudinally after surgery (every 3 months during the first
year after surgery, every 6 months for 3 years after surgery, and every 12 months for up to
5 years after surgery).
• Results showed no statistical difference in QOL scores between the two
groups

34. Postoperative QoL
• Kunisaki et al. PGSAS NEXT survey study. Ann Surg Oncol 2022;
• Enrolled 1020 (TG) + 518 (PG)
• PG (518)
EG Reconstruction (58%); (details regarding anti-reflux procedures unknown)
DTR(33%),
Jejunal interposition (6%);
Jejunal Pouch interposition (3%).
• PG patients had significantly better scores in several main outcome measures (weight loss,
dumping syndrome, necessity for additional meals, ability to work, dissatisfaction with working,
and dissatisfaction with daily life subscales; all <0.05) and generally better scores on the reflux
subscale than TG.

35. Conclusion
Proximal gastrectomy
Standard procedrue
Early gastric cancer + upper third of stomach
Proximal Gastrectomy with reconstruction may also
improve postoperative QOL.
A large-scale randomized trial comparing the long-
term survival and functional benefits after proximal
gastrectomy is required.

36. Thank you for your attention

37. Reference:
1. Yuki Hirata, et la. The role of proximal gastrectomy in gastric cancer. Chin Clin Oncol 2022;11(5):39 |
https://dx.doi.org/10.21037/cco-22-82
2. Japanese Gastric Cancer Association(JGCA). Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition) 2023
Jan;26(1):1-25. PMID: 36342574; PMCID: PMC9813208; doi: 10.1007/s10120-022-01331-8. Epub 2022 Nov 7.
3. Eom SS, Choi W, Eom BW, Park SH, Kim SJ, Kim YI, Yoon HM, Lee JY, Kim CG, Kim HK, Kook MC, Choi IJ, Kim YW, Park YI, Ryu
KW. A Comprehensive and Comparative Review of Global Gastric Cancer Treatment Guidelines. J Gastric Cancer. 2022
Mar;22(1):323.https://doi.org/10.5230/jgc.2022.22.e10
4. Wang FH, Zhang XT, Li YF, Tang L, Qu XJ, Ying JE, Zhang J, et la. The Chinese Society of Clinical Oncology (CSCO): Clinical
guidelines for the diagnosis and treatment of gastric cancer, 2021. Cancer Commun (Lond). 2021 Aug;41(8):747-795. doi:
10.1002/cac2.12193. Epub 2021 Jul 1. PMID: 34197702; PMCID: PMC8360643.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360643/
5. Terayama M, Ohashi M, Ida S, et la. Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third
Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival. J Gastric Cancer.
2023;23:e9. https://doi.org/10.5230/jgc.2023.23.e9
6. Li H, Zhang H, Zhang H, Wang Y, Wang X, Hou H; Global Health Epidemiology Reference Group. Survival of gastric cancer in
China from 2000 to 2022: A nationwide systematic review of hospital-based studies. J Glob Health. 2022 Dec 17;12:11014.
doi: 10.7189/jogh.12.11014. PMID: 36527356; PMCID:
PMC9759711.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9759711/
7. Nunobe S, Ida S. Current status of proximal gastrectomy for gastric and esophagogastric junctional cancer: A review. Ann
Gastroenterol Surg. 2020 Jun 21;4(5):498-504. doi: 10.1002/ags3.12365. PMID: 33005844; PMCID: PMC7511558.
8. Omori, T., Yamamoto, K., Yanagimoto, Y. et al. A Novel Valvuloplastic Esophagogastrostomy Technique for Laparoscopic
Transhiatal Lower Esophagectomy and Proximal Gastrectomy for Siewert Type II Esophagogastric Junction Carcinoma—the
Tri Double-Flap Hybrid Method. J Gastrointest Surg 25, 16–27 (2021). https://doi.org/10.1007/s11605-020-04547-0
9. Ri M, Nunobe S, Makuuchi R, et al. Key Factors for Maintaining Postoperative Skeletal Muscle Mass After Laparoscopic
Proximal Gastrectomy with Double-Flap Technique Reconstruction for Early Gastric Cancer. J Gastrointest Surg
2021;25:1569-72.