DFT And DTR Compete For Best Gastric Reconstruction Methods After Surgery
Overview
This study aimed to compare the short-term clinical outcomes between two reconstruction methods—double tract reconstruction (DTR) and the double flap technique (DFT)—used after laparoscopic proximal gastrectomy (LPG). The analysis was conducted retrospectively, examining data from patients who underwent these procedures between January 2020 and March 2023. To ensure a fair comparison, propensity score matching (PSM) was applied to balance the baseline characteristics of the two groups.
In total, 72 patients were included, with 48 undergoing DTR and 24 undergoing DFT. The results showed that the anastomosis time was significantly longer in the DFT group compared to the DTR group (70.1 vs. 52.7 minutes, p < 0.001). Despite the longer surgery time, DFT was associated with faster recovery indicators, including shorter times for gas passage, starting a diet, and a shorter postoperative hospital stay (p < 0.001). There were no significant differences in early and late postoperative complications between the two groups (p = 0.710 and p = 1.000, respectively).
DFT was found to be more effective than DTR in maintaining nutritional status, as indicated by better body weight maintenance, higher total protein levels (p = 0.011), and improved albumin levels (p = 0.018). Regarding quality of life (QOL), DTR performed better on the meal-related distress subscale (p < 0.001), whereas DFT was superior in reducing symptoms related to diarrhea, constipation, and dumping syndrome (p < 0.05).
In conclusion, the double flap technique (DFT) demonstrated advantages over double tract reconstruction (DTR) in facilitating early postoperative recovery, maintaining nutritional status, and enhancing quality of life. Based on these findings, DFT may be considered the preferred method for reconstruction following laparoscopic proximal gastrectomy.
Introduction
The global incidence and mortality of gastric cancer are decreasing overall, but the rate of proximal gastric cancer (PGC) is rising, particularly in Western Europe and East Asia. PGC, which occurs in the cardia and upper third of the stomach, is typically treated with total gastrectomy (TG) and D2 lymphadenectomy. This approach is effective for tumor removal but results in complete loss of gastric function and subsequent postoperative malnutrition.
Proximal gastrectomy (PG), a function-preserving alternative, offers comparable oncologic safety and feasibility while helping maintain postoperative weight and improve quality of life. However, PG disrupts the normal antireflux mechanism at the cardia, leading to issues with gastroesophageal reflux. To address this, various reconstruction techniques have been developed, including gastric tube reconstruction, jejunal interposition, double tract reconstruction (DTR), and the double flap technique (DFT).
DTR creates two digestive pathways to alleviate reflux symptoms but involves a complex surgical procedure. Conversely, DFT utilizes H-shaped double seromuscular flaps to act as a one-way valve, which can prevent reflux but carries a risk of anastomotic stenosis. Both DTR and DFT have shown promising outcomes in terms of postoperative survival and nutritional status, potentially offering advantages over TG.
The comparative effectiveness of DTR and DFT remains uncertain, with some studies suggesting DFT may be superior. Further research is needed to thoroughly evaluate these reconstruction methods by examining surgical outcomes, postoperative complications, nutritional status, and quality of life for patients with proximal gastric cancer.
Method
Between January 2020 and March 2023, a study was conducted at the First Affiliated Hospital of Xi’an Jiaotong University involving 286 patients with proximal gastric cancer. The study focused on patients who met the following inclusion criteria: proximal gastric cancer classified as cT1-2N0M0, complete clinicopathological data, no prior neoadjuvant therapy, underwent laparoscopic proximal gastrectomy (LPG), and achieved R0 resection. Patients were excluded if they had non-DTR or DFT reconstructions, primary tumors at multiple sites, or follow-up of less than one year.
From the initial cohort, 80 patients were in the DTR group and 24 in the DFT group. After applying propensity score matching to balance factors such as age, sex, body mass index (BMI), ASA physical status score, tumor size, and pathological stage, 48 patients with DTR and 24 with DFT were selected for the study. This retrospective cohort study received approval from the hospital’s ethics committee, and informed consent was waived due to its retrospective nature.
The surgical procedures followed the Japanese Gastric Cancer Treatment Guidelines, with LPG and D1+ lymphadenectomy performed to preserve at least half of the stomach volume. Chief surgeons Lin Fan and Xiangming Che, both with over 20 years of experience and more than 1000 laparoscopic procedures, oversaw the study’s key stages and quality control.
In the DTR procedure, the jejunum was transected, and side-to-side anastomosis of the esophagus was conducted, followed by gastrojejunostomy and jejunojejunostomy. In contrast, the DFT procedure involved marking the remnant stomach with an H-shaped incision, creating seromuscular flaps, and performing an esophagogastrostomy using continuous sutures. DFT was preferred for remnant stomachs close to two-thirds of the original volume, while DTR was used when tumor invasion required extended esophageal resection.
Data collection included patient demographics, surgical outcomes such as operation time and blood loss, postoperative recovery metrics, and early and late complications. Follow-up assessments measured body weight, hematologic parameters, nutritional status, and quality of life using the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45. The study’s results contribute to understanding the outcomes and complications associated with different reconstruction techniques following laparoscopic proximal gastrectomy.
Statistical analysis
Statistical analyses were conducted using SPSS version 24.0 (SPSS/IBM). Continuous data are reported as mean ± standard deviation (SD) or median (range), with Student’s t-test or the Mann-Whitney U test used for comparisons between groups. Categorical variables are presented as percentages, and Fisher’s exact test was employed to assess differences between groups. A logistic regression model with a caliper of 0.2 standard deviations was utilized for propensity score matching (PSM) analysis. All statistical tests were two-sided, with a significance threshold set at p < 0.05.
Result
The study investigates the clinicopathological features and surgical outcomes of patients undergoing LPG-DTR and LPG-DFT procedures, comparing characteristics before and after matching.
Initially, significant differences were observed between the two groups in terms of age (p = 0.001), BMI (p = 0.040), and tumor size (p = 0.019). Both groups commonly used S-1 and SOX adjuvant chemotherapy for pathological stage II cancer.
Regarding surgical outcomes and postoperative complications, both groups had comparable operative times, estimated blood loss, and number of retrieved lymph nodes. However, the DFT group had a significantly longer anastomosis time (70.1 vs. 52.7 minutes, p < 0.001). The DFT group also had shorter recovery times, with fewer days required for gas passing (3.0 vs. 4.0 days, p < 0.001) and diet initiation (4.0 vs. 5.0 days, p < 0.001), and a shorter hospital stay (8.5 vs. 10.0 days, p < 0.001). Although early and late complication rates were lower in the DFT group (8.3%) compared to the DTR group (12.5% and 10.4%), the differences were not statistically significant (p = 0.710 and p = 1.000, respectively). Both groups had patients who developed pneumonia and reflux esophagitis, though none had severe symptoms or required significant interventions.
Further analysis of postoperative complications within the DFT group did not show significant differences between intra-abdominal DFT (IA-DFT) and intra-mediastinal DFT (IM-DFT) groups.
In terms of body weight and nutritional status, the DFT group experienced less weight loss compared to the DTR group at 12 months post-surgery (−5.6% vs. −11.6%, p = 0.012). Additionally, total protein and albumin levels were significantly higher in the DFT group at 12 months (−3.5% vs. −9.9%, p = 0.011; −4.5% vs. −10.2%, p = 0.018). No significant differences were observed in cholesterol, lymphocyte count, hemoglobin, or vitamin B12 levels. The CONUT score, a measure of nutritional status, remained similar across both groups at 6 and 12 months after surgery, with no severe malnutrition reported.
Quality of life (QOL) assessments, conducted a median of 16 months post-surgery, revealed that the DTR group had lower meal-related distress compared to the DFT group (1.6 vs. 2.1, p < 0.001). Conversely, the DFT group had better outcomes in terms of diarrhea (1.6 vs. 1.8, p = 0.005), constipation (1.8 vs. 2.0, p = 0.022), and dumping symptoms (1.4 vs. 1.6, p = 0.007). Despite differences in specific symptoms, the overall symptom scores were similar between the groups (DTR 1.8 vs. DFT 1.7, p = 0.520), indicating overall acceptable postoperative outcomes for both groups.
Conclusion
Research indicates that various reconstruction methods after proximal gastrectomy (PG) offer different benefits, with double tract reconstruction (DTR) and double flap technique (DFT) being prominent. Both methods show oncological safety and improved postoperative nutritional outcomes. This study highlights the advantages of DFT in multiple aspects.
The double tract reconstruction, introduced by Aikou and modified as DFT, has been effective in reducing postoperative reflux esophagitis. Meta-analyses show that the incidence of reflux esophagitis is comparable between DFT (8.9%) and DTR (8.6%), both lower than esophagogastrostomy (EG) (19.3%). Adjusting the length of the interposed jejunum in DTR has been suggested to reduce reflux, though excessive length can complicate endoscopy.
DFT, which maintains a physiological digestive pathway, has shown promising results in preventing reflux. However, it is associated with a higher rate of anastomotic stenosis. Previous studies report an anastomotic stenosis incidence of 0-13.3% in DTR, with a similar finding (2.1%) in this study’s DTR cohort. Modifications in flap design and the use of V-Loc for anastomosis have been suggested to reduce stenosis, with our study showing a 4.2% incidence in the DFT group.
Postoperative nutritional status was better in the DFT group compared to DTR, with higher body weight and albumin levels at one year post-surgery. DFT allows food to pass through the remnant stomach and duodenum, enhancing nutrient absorption. In contrast, DTR limits food entry into the remnant stomach, impacting nutritional outcomes. Enlarging the gastrojejunostomy in DTR may improve postoperative nutrition.
Quality of life (QoL) after PG is also a key concern. Although DFT and DTR offer similar outcomes for esophageal reflux, DFT patients reported worse meal-related distress, possibly due to the jejunum pathway’s impact on gastric emptying. However, DTR patients experienced more diarrhea and constipation, potentially due to inadequate food digestion.
The study’s limitations include its retrospective nature and the short-term follow-up, which may not fully capture long-term outcomes. The small sample size and lack of multivariate analysis also limit the ability to generalize findings.
In summary, despite its complexity and longer anastomosis time, DFT appears to offer superior benefits over DTR in terms of early recovery, nutritional status, and QoL after PG.
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