Can Proximal Gastrectomy with Double-Tract Reconstruction Replace Total Gastrectomy? A Propensity Score Matching Analysis

  • Hyo Jung Ko
  • Ki Hyun Kim
  • Si-Hak Lee
  • Cheol Woong Choi
  • Su Jin Kim
  • Chang In Choi
  • Dae-Hwan Kim
  • Dong-Heon Kim
  • Sun-Hwi HwangEmail author
Original Article



This retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical outcomes.


All consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008–2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality.


Of 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (p = 0.02), smaller proximal and distal resection margins (p = 0.01, p < 0.01), and fewer retrieved lymph nodes (p < 0.01). PG-DTR associated with shorter times to diet and hospital stay (both p = 0.02). Groups did not differ in early (11.3 vs. 19.2%, p = 0.19), late (1.9 vs. 5.7%, p = 0.31), or severe complication rates (7.7 vs. 13.5%, p = 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (p = 0.02), respectively.


PG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.


Proximal gastrectomy Double-tract reconstruction Total gastrectomy Upper gastric cancer Propensity score matching 


Author Contributions

Study conception and design: Hwang, DH Kim.

Acquisition, analysis, and interpretation of data: Ko, KH Kim, Lee, Hwang.

Drafting of manuscript or critical revision: Ko, KH Kim, Lee, CW Choi, SJ Kim, CI Choi, DH Kim.

Final approval of the version: Hwang.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Torre LA, Siegel RL, Ward EM, Jemal A. Global Cancer Incidence and Mortality Rates and Trends--An Update. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2016;25(1):16–27.CrossRefGoogle Scholar
  2. 2.
    Ministry of Health and Welfare. Annual Report of Cancer statistics in Korea in 2015. 2017.Google Scholar
  3. 3.
    Jeong O, Park YK. Clinicopathological features and surgical treatment of gastric cancer in South Korea: the results of 2009 nationwide survey on surgically treated gastric cancer patients. Journal of gastric cancer. 2011;11(2):69–77.CrossRefGoogle Scholar
  4. 4.
    Information Committee of Korean Gastric Cancer A. Korean Gastric Cancer Association Nationwide Survey on Gastric Cancer in 2014. Journal of gastric cancer. 2016;16(3):131–40.CrossRefGoogle Scholar
  5. 5.
    Ikeguchi M, Kader A, Takaya S, Fukumoto Y, Osaki T, Saito H, Tatebe S, Wakatsuki T. Prognosis of patients with gastric cancer who underwent proximal gastrectomy. International surgery. 2012;97(3):275–9.CrossRefGoogle Scholar
  6. 6.
    Kosuga T, Ichikawa D, Komatsu S, Okamoto K, Konishi H, Shiozaki A, Fujiwara H, Otsuji E. Feasibility and Nutritional Benefits of Laparoscopic Proximal Gastrectomy for Early Gastric Cancer in the Upper Stomach. Annals of surgical oncology. 2015;22 Suppl 3:S929–35.Google Scholar
  7. 7.
    Takiguchi N, Takahashi M, Ikeda M,Inagawa S, Ueda S, Nobuoka T, Ota M, Iwasaki Y, Uchida N, Kodera Y, Nakada K. Long-term quality-of-life comparison of total gastrectomy and proximal gastrectomy by postgastrectomy syndrome assessment scale (PGSAS-45): a nationwide multi-institutional study. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2015;18(2):407–16.CrossRefGoogle Scholar
  8. 8.
    Jung DH, Ahn SH, Park DJ, Kim HH. Proximal Gastrectomy for Gastric Cancer. Journal of gastric cancer. 2015;15(2):77–86.CrossRefGoogle Scholar
  9. 9.
    Japanese Gastric Cancer A. Japanese classification of gastric carcinoma: 3rd English edition. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2011;14(2):101–12.Google Scholar
  10. 10.
    Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Annals of surgery. 2009;250(2):187–96.CrossRefGoogle Scholar
  11. 11.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of surgery. 2004;240(2):205–13.CrossRefGoogle Scholar
  12. 12.
    Visick AH. A study of the failures after gastrectomy. Annals of the Royal College of Surgeons of England. 1948;3(5):266–84.Google Scholar
  13. 13.
    Kubo M, Sasako M, Gotoda T, Ono H, Fujishiro M, Saito D, Sano T, Katai H. Endoscopic evaluation of the remnant stomach after gastrectomy: proposal for a new classification. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2002;5(2):83–9.CrossRefGoogle Scholar
  14. 14.
    Ahn SH, Jung DH, Son SY, Lee CM, Park DJ, Kim HH. Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association. 2014;17(3):562–70.CrossRefGoogle Scholar
  15. 15.
    Sategna-Guidetti C, Bianco L. Malnutrition and malabsorption after total gastrectomy. A pathophysiologic approach. Journal of clinical gastroenterology. 1989;11(5):518–24.CrossRefGoogle Scholar
  16. 16.
    Bae JM, Park JW, Yang HK, Kim JP. Nutritional status of gastric cancer patients after total gastrectomy. World journal of surgery. 1998;22(3):254–60; discussion 60-1.CrossRefGoogle Scholar
  17. 17.
    Fujiya K, Kawamura T, Omae K, Makuuchi R, Irino T, Tokunaga M, Tanizawa Y, Bando E, Terashima M. Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Annals of surgical oncology. 2018;25(4):974–83.CrossRefGoogle Scholar
  18. 18.
    Park DJ, Lee HK, Lee HJ, Kim WH, Yang HK, Lee KU, Choe KJ. Lymph node metastasis in early gastric cancer with submucosal invasion: feasibility of minimally invasive surgery. World journal of gastroenterology. 2004;10(24):3549–52.CrossRefGoogle Scholar
  19. 19.
    Kitamura K, Yamaguchi T, Nishida S, Yamamoto K, Ichikawa D, Okamoto K, Taniguchi H, Hagiwara A, Sawai K, Takahashi T. The operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach. Surgery today. 1997;27(11):993–8.CrossRefGoogle Scholar
  20. 20.
    Yang HK. Issues in the management of the upper third gastric cancer. Cancer research and treatment : official journal of Korean Cancer Association. 2004;36(1):4–5.CrossRefGoogle Scholar
  21. 21.
    Hur K, Kwak MK, Lee HJ, Park DJ, Lee HK, Lee HS, Kim WH, Michaeli D, Yang HK. Expression of gastrin and its receptor in human gastric cancer tissues. Journal of cancer research and clinical oncology. 2006;132(2):85–91.CrossRefGoogle Scholar
  22. 22.
    Smith JP, Nadella S, Osborne N. Gastrin and Gastric Cancer. Cellular and molecular gastroenterology and hepatology. 2017;4(1):75–83.CrossRefGoogle Scholar
  23. 23.
    Ronellenfitsch U, Najmeh S, Andalib A, Perera RM, Rousseau MC, Mulder DS, Ferri LE. Functional outcomes and quality of life after proximal gastrectomy with esophagogastrostomy using a narrow gastric conduit. Annals of surgical oncology. 2015;22(3):772–9.CrossRefGoogle Scholar
  24. 24.
    Fennerty MB, Johnson DA. Heartburn severity does not predict disease severity in patients with erosive esophagitis. MedGenMed : Medscape general medicine. 2006;8(2):6.Google Scholar
  25. 25.
    Garland SN, Pelletier G, Lawe A, Biagioni BJ, Easaw J, Eliasziw M, Cella D, Bathe OF. Prospective evaluation of the reliability, validity, and minimally important difference of the functional assessment of cancer therapy-gastric (FACT-Ga) quality-of-life instrument. Cancer. 2011;117(6):1302–12.CrossRefGoogle Scholar
  26. 26.
    Blazeby JM, Conroy T, Bottomley A,Vickery C, Arraras J, Sezer O, Moore J, Koller M, Turhal NS, Stuart R, Van Cutsem E, D’haese S, Coens C. Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-STO 22, to assess quality of life in patients with gastric cancer. European journal of cancer. 2004;40(15):2260–8.CrossRefGoogle Scholar
  27. 27.
    Saito T, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Current status of function-preserving surgery for gastric cancer. World journal of gastroenterology. 2014;20(46):17297–304.CrossRefGoogle Scholar
  28. 28.
    Jung DH, Lee Y, Kim DW, Park YS, Ahn SH, Park DJ, Kim HH. Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer. Surgical endoscopy. 2017;31(10):3961–9.CrossRefGoogle Scholar
  29. 29.
    Lee JH, Hyung WJ, Kim HI, Kim YM, Son T, Okumura N, Hu Y, Kim CB, Noh SH. Method of reconstruction governs iron metabolism after gastrectomy for patients with gastric cancer. Annals of surgery. 2013;258(6):964–9.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Hyo Jung Ko
    • 1
  • Ki Hyun Kim
    • 1
  • Si-Hak Lee
    • 1
  • Cheol Woong Choi
    • 2
  • Su Jin Kim
    • 2
  • Chang In Choi
    • 3
  • Dae-Hwan Kim
    • 3
  • Dong-Heon Kim
    • 3
  • Sun-Hwi Hwang
    • 1
    Email author
  1. 1.Department of Surgery and Research Institute for Convergence of Biomedical Science and TechnologyPusan National University Yangsan HospitalYangsanRepublic of Korea
  2. 2.Department of Internal MedicinePusan National University Yangsan HospitalYangsanRepublic of Korea
  3. 3.Department of SurgeryPusan National UniversityPusanRepublic of Korea

Personalised recommendations