背景:根据日本胃癌治疗指南第5版,对于R0切除后能保留残胃远端一半的早期上胃癌患者,建议行近端胃切除术.然而,最近的大量临床研究表明,指南中的近端胃切除术的手术指征可能过于狭窄。因此,这项荟萃分析纳入了早期和晚期胃癌患者,并比较了两组的短期和长期术后结局.同时,我们只有高质量的临床研究,如倾向评分匹配研究和随机对照试验,这使得我们的研究更加真实可信。
方法:数据来自PubMed,EMBASE,Medline,和截至2023年6月的Cochrane图书馆,包括近端胃切除术后双道重建术和全胃切除术后Roux-en-Y重建术的治疗结果。主要结果是早期并发症(吻合口漏,吻合口出血,腹部脓肿,腹腔感染,肺部感染,切口感染,肠梗阻,倾倒综合征,胰腺瘘),晚期并发症(肠梗阻,吻合口狭窄,倾倒综合征,再操作,内疝,内镜下胃食管反流的发生率),严重并发症(≥III级C-D评分),生活质量[胃食管反流症状评估(Visick评分)(≥III),洛杉矶分类(C或D)],营养状况(血红蛋白,收到维生素B12补充剂),肿瘤学结果(5年总生存率)。次要结果是手术结果(手术时间,估计失血,术后住院时间,收集的淋巴结数量,气体通过,术后死亡率)。使用Cochrane偏倚风险工具和纽卡斯尔-渥太华量表评估纳入研究的质量。
结果:筛选后,最终纳入了11项研究,包括1154名患者。综合文献结果显示,全胃切除术在平均手术时间上优于近端胃切除术双道重建术(MD=4.92,95%CI:0.22~9.61P=0.04)。然而,荟萃分析结果显示,近端胃双道重建组的血红蛋白(MD=7.12,95%CI:2.40~11.84,P=0.003)和补充维生素B12(OR=0.12,95%CI:0.05~0.26,P<0.00001)优于全胃切除术Roux-en-Y重建组。近端胃切除双道重建术与全胃切除术Roux-en-Y重建术组早期并发症比较差异无统计学意义(OR=1.14,95%CI:0.79~1.64,P=0.50)。晚期并发症(OR=1.37,95%CI:0.78~2.39,P=0.27),胃食管反流症状评估(Visick评分)(≥III)(OR=0.94,95%CI:0.14~1.07P=0.07),洛杉矶分类(C或D)(OR=0.33,95%CI:0.01~8.21,P=0.50),5年总生存率(HR=1.01,95%CI:0.83~1.23,P=0.89)。
结论:近端胃切除双道吻合术是治疗胃上部癌安全可行的方法。然而,与Roux-en-Y组的全胃切除术相比,双道近端胃切除术组的手术时间稍长.两组在严重并发症(≥Ⅲ级C-D评分)方面与Roux-en-Y组全胃切除术相当,早期并发症,晚期并发症,和生活质量。尽管近端胃切除术的范围小于全胃切除术,它不影响5年生存率,提示患者肿瘤预后良好。与Roux-en-Y组全胃切除术相比,双道重建近端胃切除术的血红蛋白水平较高,补充维生素B12的可能性较低,且远期疗效较好。总之,近端胃切除双道重建术被认为是较合理的手术方式之一。
BACKGROUND: According to the 5th edition of the Japanese Guidelines for the Treatment of Gastric Cancer, proximal gastrectomy is recommended for patients with early upper gastric cancer who can retain the distal half of the residual stomach after R0 resection. However, a large number of recent clinical studies suggest that surgical indications for proximal gastrectomy in the guidelines may be too narrow. Therefore, this meta-analysis included patients with early and advanced gastric cancer and compared short- and long-term postoperative outcomes between the two groups. At the same time, we only had high-quality clinical studies such as propensity score-matched studies and randomized controlled trials, which made our research more authentic and credible.
METHODS: Data were retrieved from PubMed, EMBASE, Medline, and Cochrane Library up to June 2023, and included treatment outcomes after proximal gastrectomy with double-tract reconstruction and total gastrectomy with Roux-en-Y reconstruction. The primary results were Early-phase complications(Anastomotic leakage, Anastomotic bleeding, Abdominal abscess, Abdominal infection, Pulmonary infection, Incision infection, Intestinal obstruction, Dumping syndrome, Pancreatic fistula), Late-phase complications(Intestinal obstruction, Anastomosis stricture, Dumping syndrome, Reoperation, Internal hernia, Incidence of endoscopic gastroesophageal reflux), Serious complications (≥ Grade III C-D score), Quality of life[Gastroesophageal reflux symptom evaluation (Visick score)(≥ III), Los Angeles classification(C or D)], Nutritional status(Hemoglobin, Receipt of vitamin B12 supplementation), Oncologic Outcomes(The 5-year overall survival rates). Secondary outcomes were surgical outcomes (Operative time, Estimated blood loss, Postoperative hospital stay, Number of harvested lymph nodes, Gas-passing, Postoperative mortality).The Cochrane risk-of-bias tool and Newcastle‒Ottawa scale were used to assess the quality of the included studies.
RESULTS: After screening, 11 studies were finally included, including 1154 patients. Results from the combined literature showed that total gastrectomy had a significant advantage over proximal gastrectomy with double-tract reconstruction in mean operating time (MD = 4.92, 95% CI: 0.22∼9.61 P = 0.04). However, meta-analysis results showed that Hemoglobin (MD = 7.12, 95% CI:2.40∼11.84, P = 0.003) and Receipt of vitamin B12 supplementation (OR = 0.12, 95% CI:0.05∼0.26, P < 0.00001) in the proximal gastrectomy with double-tract reconstruction group were better than those in the total gastrectomy with Roux-en-Y reconstruction group. There is no significant difference between the proximal gastrectomy with double-tract reconstruction and the total gastrectomy with Roux-en-Y reconstruction group in Early-phase complications(OR = 1.14,95% CI:0.79∼1.64, P = 0.50), Late-phase complications(OR = 1.37,95% CI:0.78∼2.39, P = 0.27), Gastroesophageal reflux symptom evaluation (Visick score)(≥ III)(OR = 0.94,95% CI:0.14∼1.07 P = 0.07), Los Angeles classification(C or D)(OR = 0.33,95% CI:0.01∼8.21, P = 0.50), the 5-year overall survival rates (HR = 1.01, 95% CI: 0.83 ~ 1.23, P = 0.89).
CONCLUSIONS: Proximal gastrectomy with double-tract anastomosis is a safe and feasible treatment for upper gastric carcinoma. However, the operating time was slightly longer in the proximal gastrectomy with double-tract group compared to the total gastrectomy with Roux-en-Y group. The two groups were comparable to the total gastrectomy with Roux-en-Y group in terms of serious complications (≥ Grade III C-D score), early-phase complications, late-phase complications, and quality of life. Although the scope of proximal gastrectomy is smaller than that of total gastrectomy, it does not affect the 5-year survival rate, indicating good tumor outcomes for patients. Compared to total gastrectomy with Roux-en-Y group, proximal gastrectomy with double-tract reconstruction had higher hemoglobin levels, lower probability of vitamin B12 supplementation, and better long-term efficacy. In conclusion, proximal gastrectomy with double-tract reconstruction is considered one of the more rational surgical approaches for upper gastric cancer.