Clinical efficacy and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in gastrectomy

Abstract

BACKGROUND

With the continuous progress of surgical technology and improvements in medical standards, the treatment of gastric cancer surgery is also evolving. Proximal gastrectomy is a common treatment, but double-channel anastomosis and tubular gastroesophageal anastomosis have attracted much attention in terms of surgical options. Each of these two surgical methods has advantages and disadvantages, so it is particularly important to compare and analyze their clinical efficacy and safety.

AIM

To compare the surgical safety, clinical efficacy, and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in proximal gastrectomy.

METHODS

The clinical and follow-up data of 99 patients with proximal gastric cancer who underwent proximal gastrectomy and were admitted to our hospital between January 2018 and September 2023 were included in this retrospective cohort study. According to the different anastomosis methods used, the patients were divided into a double-channel anastomosis group (50 patients) and a tubular gastroesophageal anastomosis group (49 patients). In the double-channel anastomosis, Roux-en-Y anastomosis of the esophagus and jejunum was performed after proximal gastric dissection, and then side-to-side anastomosis was performed between the residual stomach and jejunum to establish an antireflux barrier and reduce postoperative gastroesophageal reflux. In the tubular gastroesophageal anastomosis group, after the proximal end of the stomach was cut, tubular gastroplasty was performed on the distal stump of the stomach and a linear stapler was used to anastomose the posterior wall of the esophagus and the anterior wall of the stomach tube. The main outcome measure was quality of life 1 year after surgery in both groups, and the evaluation criteria were based on the postgastrectomy syndrome assessment scale. The greater the changes in body mass, food intake per meal, meal quality subscale score, and total measures of physical and mental health score, the better the condition; the greater the other indicators, the worse the condition. The secondary outcome measures were intraoperative and postoperative conditions, the incidence of postoperative long-term complications, and changes in nutritional status at 1, 3, 6, and 12 months after surgery.

RESULTS

In the double-channel anastomosis cohort, there were 35 males (70%) and 15 females (30%), 33 (66.0%) were under 65 years of age, and 37 (74.0%) had a body mass index ranging from 18 to 25 kg/m². In the group undergoing tubular gastroesophageal anastomosis, there were eight females (16.3%), 21 (42.9%) individuals were under the age of 65 years, and 34 (69.4%) had a body mass index ranging from 18 to 25 kg/m². The baseline data did not significantly differ between the two groups (P > 0.05 for all), with the exception of age (P = 0.021). The duration of hospitalization, number of lymph nodes dissected, intraoperative blood loss, and perioperative complication rate did not differ significantly between the two groups (P > 0.05 for all). Patients in the dual-channel anastomosis group scored better on quality of life measures than did those in the tubular gastroesophageal anastomosis group. Specifically, they had lower scores for esophageal reflux [2.8 (2.3, 4.0) vs 4.8 (3.8, 5.0), Z = 3.489, P < 0.001], eating discomfort [2.7 (1.7, 3.0) vs 3.3 (2.7, 4.0), Z = 3.393, P = 0.001], total symptoms [2.3 (1.7, 2.7) vs 2.5 (2.2, 2.9), Z = 2.243, P = 0.025], and other aspects of quality of life. The postoperative symptoms [2.0 (1.0, 3.0) vs 2.0 (2.0, 3.0), Z = 2.127, P = 0.033], meals [2.0 (1.0, 2.0) vs 2.0 (2.0, 3.0), Z = 3.976, P < 0.001], work [1.0 (1.0, 2.0) vs 2.0 (1.0, 2.0), Z = 2.279, P = 0.023], and daily life [1.7 (1.3, 2.0) vs 2.0 (2.0, 2.3), Z = 3.950, P < 0.001] were all better than those of the tubular gastroesophageal anastomosis group. The group that underwent tubular gastroesophageal anastomosis had a superior anal exhaust score [3.0 (2.0, 4.0) vs 3.5 (2.0, 5.0) (Z = 2.345, P = 0.019] compared to the dual-channel anastomosis group. Hemoglobin, serum albumin, total serum protein, and the rate at which body mass decreased one year following surgery did not differ significantly between the two groups (P > 0.05 for all).

CONCLUSION

The safety of double-channel anastomosis in proximal gastric cancer surgery is equivalent to that of tubular gastric surgery. Compared with tubular gastric surgery, double-channel anastomosis is a preferred surgical technique for proximal gastric cancer. It offers advantages such as less esophageal reflux and improved quality of life.

Key Words: Gastric neoplasms; Proximal gastrectomy; Digestive tract reconstruction; Dual channel reconstruction; Tubular stomach reconstruction; Retrospective cohort study

Core Tip: This study compared the clinical efficacy and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in proximal gastrectomy. The clinical data of the patients, including surgical indications, surgical methods, postoperative complications, and follow-up results, were retrospectively analyzed to evaluate the differences in surgical treatment effect and postoperative safety between the two anastomotic methods. This study focused on indicators such as the postoperative complication rate, incidence of anastomotic fistula, postoperative discharge time, nutritional status, and quality of life during long-term follow-up to comprehensively compare the advantages and disadvantages of the two surgical methods and provide a reference for clinicians to choose the best treatment plan.

INTRODUCTION

The main surgical procedures for proximal gastric cancer include total gastrectomy and proximal gastrectomy[1-3]. Proximal gastrectomy, which preserves at least half of the stomach, is generally used only for early-stage upper gastric cancer. According to the 6th edition of the Japanese Guidelines for the Treatment of Gastric Cancer, proximal gastrectomy is a weak recommendation for esophagogastric junction cancer, but total gastrectomy is recommended for patients with a large tumor diameter and gastric invasion[4]. The high incidence of reflux esophagitis after proximal gastrectomy has severely limited the application of proximal gastrectomy[5]. With the development of the concept of functional preservation surgery in recent years, an increasing number of proximal gastrectomy and digestive tract reconstruction procedures, including double-channel anastomosis, tubular gastroesophageal anastomosis, jejunal interposition, and double muscle flap reconstruction, have been applied in clinical practice[6]. However, the antireflux effect and advantages and disadvantages of these procedures are still controversial, and there is no optimal method for gastrointestinal reconstruction after proximal gastrectomy[7].

Among the reconstruction methods mentioned above, tubular gastroesophageal anastomosis and double-channel anastomosis are two relatively mature antireflux surgery methods[8-10]. Compared with traditional residual gastroesophageal anastomosis, tubular gastroesophageal anastomosis excises part of the gastric antrum, reduces gastric acid secretion, increases the gastric acid reflux path, and significantly improves long-term postoperative quality of life[11]. However, the current literature reports that the postoperative antireflux effect is not ideal, and the incidence of reflux symptoms is as high as 14%-35%. Double-channel anastomosis avoids direct entry of gastric acid into the esophagus, and the incidence of reflux symptoms reported in the literature ranges from 1.1% to 10.0%[12]. However, in some cases, when double-channel anastomosis occurs, food will escape from the jejunal path and not enter the residual gastric path, which leads to the possibility that double-channel reconstruction may not be beneficial to patients[13-15].

At present, most studies on the quality of life of patients after proximal gastrectomy have focused on comparisons between traditional esophagogastric anastomosis, double-channel anastomosis, and double muscle flap anastomosis. However, there are few reports comparing tubular gastroesophageal anastomosis and double-channel anastomosis[16-18]. Therefore, the present study retrospectively analyzed the effects of double-channel anastomosis and tubular gastroesophageal anastomosis on the quality of life of patients with stages I and II proximal gastric cancer after proximal gastrectomy to provide a further reference for the selection of digestive tract reconstruction methods for proximal gastric cancer.

MATERIALS AND METHODS

Research subjects

A retrospective cohort study design was used in this study. The inclusion criteria were as follows: (1) Primary gastric adenocarcinoma was confirmed by preoperative endoscopic pathological biopsy, and the clinical stage of gastric cancer was stage I or stage II according to the 8th edition of the American Cancer Federation; (2) Preoperative computed tomography and other imaging examinations confirmed that the tumor was located in the upper 1/3 of the stomach; and (3) The surgical method was proximal gastrectomy, and the digestive tract reconstruction method was double-channel anastomosis or tubular gastroesophageal anastomosis. The exclusion criteria were as follows: (1) Received preoperative neoadjuvant therapy; (2) Had tumors at other sites; (3) Did not achieve R0 excision; and (4) Had incomplete postoperative follow-up data.

According to the above criteria, the clinicopathological data of 99 patients with upper gastric adenocarcinoma admitted to the General Surgery Center of Fujian Provincial Hospital between January 2018 and September 2023 were retrospectively collected. According to the different anastomosis methods used, the patients were divided into a double-channel anastomosis group (50 patients) and a tubular gastroesophageal anastomosis group (49 patients). The comparison of baseline data between the two groups revealed no statistically significant differences except for age, as shown in Table 1.

Table 1 Comparison of baseline data between patients with proximal gastric adenocarcinoma in the dual-channel anastomosis group and the tubular gastroesophageal anastomosis group, n (%).

Group	Cases	Age			Gender		Body mass index
		≤ 65 years old	> 65 years old		Male	Female	< 18 kg/m²	18-25 kg/m²	> 25 kg/m²
Dual-channel anastomosis group	50	33 (66.0)	17 (34.0)		35 (70.0	15 (30.0)	1 (2.0)	37 (74.0)	12 (24.0)
Tubular gastroesophageal anastomosis group	49	21 (42.9)	28 (57.1)		41 (83.7)	8 (16.3)	0	34 (69.4)	15 (30.6)
χ2		5.346			2.594		1.392
P value		0.021			0.107		0.577
Group	Cases	American Society of Anesthesiologists Classification			Hypertension		Coronary heart disease		Diabetes
		I	Ⅱ		Yes	No	Yes	No	Yes	No
Dual-channel anastomosis group	50	37 (74.0)	13 (26.0)		18 (36.0)	32 (64.0)	1 (2.0)	49 (98.0)	6 (12.0)	44 (88.0)
Tubular gastroesophageal anastomosis group	49	36 (73.5)	13 (26.5)		16 (32.7)	33 (67.3)	0	49 (100)	6 (12, 2)	43 (87.8)
χ2		0.004			0.123		0.99		0.001
P value		0.952			0.726		0.32		0.97
Group	Cases	Tumor T-stage			Tumor N-stage		Tumor TNM-stage		Tumor diameter
		Tl	T2	T3	NO	N1	I	Ⅱ	< 4 cm	24 cm
Dual-channel anastomosis group	50	36 (72.0)	11 (22.0)	3 (6.0)	46 (92.0)	4 (8.0)	42 (84.0)	8 (16.0)	49 (98.0)	1 (2.0)
Tubular gastroesophageal anastomosis group	49	34 (69.4)	6 (12.2)	9 (18.4)	49 (100)	0	40 (81.6)	9 (18.4)	44 (89.9)	5 (10.2)
χ2		4.518			2.282		0.098		1.662
P value		0.104			0.131		0.755		0.197

All patients and their families provided informed consent before the operation. The Ethics Committee of Fujian Provincial Hospital granted approval for this study.

Mode of operation

All patients were treated with D1, D1+, and D2 Lymph node dissection according to the requirements for proximal gastrectomy. The perigastric vessels were cut, the omentum was excised, and the proximal esophagus was cut as needed. The methods used for distal digestive tract reconstruction in the two groups were as follows: (1) In the double-channel anastomosis group, the distal end was separated from the tumor margin by > 5 cm. Esophagojejunal anastomosis was performed at a distance of 10-15 cm below the Treitz's ligament, and jejjunojejunal anastomosis was performed at a distance of 25-30 cm from the proximal jejunal anastomosis (Figure 1A); and (2) In the tubular gastroplasty group, tubular gastroplasty was performed on the distal stump of the stomach, and direct anastomosis was performed between the posterior wall of the esophagus and the anterior wall of the gastric tube using a 45-mm linear stapler (Figure 1B).

Figure 1 Schematic diagram of gastrointestinal reconstruction after proximal gastrectomy. A: Double-channel anastomosis; B: Tubular gastroesophageal anastomosis.

Observation indicators and evaluation criteria

Outcome measures: Main outcome measure was quality of life 1 year after surgery. Secondary outcome measures included intraoperative and postoperative conditions, postoperative long-term complications, and changes in nutritional status 1, 3, 6, and 12 mo after surgery.

Evaluation criteria: (1) Quality of life: The post-gastrectomy syndrome assessment scale (PSAS-45), designed by the Chinese version of the Japan Working Group on Post-Gastrectomy Syndrome, was used to measure the intensity of various symptoms after gastrectomy and explain to what extent they affect the patient's life. The scale mainly consists of the symptom domain, life state domain, and life quality domain. According to the different domains, the relevant problems were graded according to different degrees, in which the higher the score of body mass change, food intake per meal, meal quality subscale, total physical health measurement, and total mental health measurement, the better the situation, and the higher the score of other indicators, the worse the situation; (2) Nutritional status: Nutritional indicators including hemoglobin, serum albumin (ALB), and serum total protein levels were evaluated. Hemoglobin < 120 g/L in men and < 110 g/L in women is defined as anemia. A serum total protein concentration < 60 g/L or a serum ALB concentration < 25 g/L is considered hypoproteinaemia; and (3) Postoperative long-term complications: Complications including gastroesophageal reflux, anastomotic stenosis, intestinal obstruction, and gastric emptying disorder, were observed 1 year after surgery. Long-term complications were diagnosed and graded according to the Clavien-Dindo grading criteria: Grade I, discomfort symptoms that do not require drug treatment or complications that only require routine management, such as antipyretic analgesia; grade II, complications requiring the use of drugs and treatment measures other than those described above; grade III, complications requiring surgical or endoscopic intervention; grade IV, serious life-threatening complications such as cerebral hemorrhage; and grade V, patient death. Patients with long-term complications ≥ grade II were included in the statistical analysis.

Follow-up method: Postoperative follow-up was conducted for 1 year, and postoperative review was performed at 1, 3, 6, and 12 months. The review included physical examination, laboratory examination (including routine blood tests, biochemical tests, etc.), and endoscopy. The patient’s somatic symptoms, status of life, and quality of life recovery were collected by telephone follow-up or questionnaire survey 12 mo after surgery, and the follow-up period ended in September 2023.

Statistical methods

All the data were processed using SPSS 26.0. Normally distributed measurement data are expressed as the mean ± SD, and two independent samples t-tests were used for comparisons between groups. Nonnormally distributed data are expressed as M (Q1, Q3), and the Mann-Whitney U test was used for comparisons between groups. Count data are represented by cases (%). χ² tests were used for comparisons between nonranked count data groups, and Mann-Whitney U tests were used for comparisons between ranked count data groups. Repeated measures analysis of variance was used to compare nutrition-related indicators before surgery and 1, 3, 6, and 12 months after surgery. P < 0.05 indicated that the difference was statistically significant.

RESULTS

Comparison of intraoperative and postoperative conditions

The operation was successful in both groups, and R0 resection was performed in both groups. There were no statistically significant differences between the two surgical methods in terms of intraoperative blood loss, number of lymph nodes dissected, operation time, length of hospital stay, or incidence of recent postoperative complications (P > 0.05), as shown in Table 2. All the patients with anastomotic bleeding were hemostatic under endoscopy, and the remaining complications were resolved by conservative symptomatic treatment; no patients who underwent a second operation were reported. A total of 24 patients in the double-channel anastomosis group completed gastrointestinal angiography 7 days after surgery, 16 (66.7%) of whom underwent double-channel imaging and 8 (33.3%) of whom underwent single-channel imaging (Figure 2).

Figure 2 Postoperative gastrointestinal angiography of patients with upper gastricadenocarcinoma in the double-channel anastomosis group. A: Dual-channel development; B: Single-channel development.

Table 2 Comparison of intraoperative and postoperative conditions between the two groups.

Group	Cases	Surgical methods		Intraoperative bleeding volume (mL)	Number of lymph nodes resected	Operative time (h)	Hospital stay (d)	Short-term complications after anastomotic surgery (%)
		Laparoscopic	Open					Total	Anastomotic bleeding	Anastomotic leakage	Gastroparesis	Pneumonia	Infect
Dual-channel anastomosis group	50	16 (32.0)	34 (68.0)	200 (100, 300)	17 (15, 21)	4 (3, 4)	16 (15, 18)	5 (10.0)	1	2	1	0	1
Tubular gastroesophageal anastomosis group	49	10 (20.4)	39 (79.6)	200 (100, 200)	20 (16, 25)	3.6 (3.1, 4.0)	14 (13, 18)	4 (8.2)	1	1	1	1	0
Statistics		χ2 = 1.717		Z = 0.245	Z = 1.866	Z = 0.102	Z = 1.463	χ2 = 0.101
P value		0.19		0.807	0.062	0.918	0.144	0.751

Postoperative quality of life assessment

At 1 year after surgery, compared with the tubular gastroesophageal anastomosis group, the double-channel anastomosis group had better scores in terms of esophageal reflux, eating discomfort, constipation, and total symptom score in the somatic symptom domain. Patients with tubular gastroesophageal anastomosis were more likely to have anal exhaust but were less likely to have loose stools. The differences were statistically significant (P < 0.05) (Table 3).

Table 3 Comparison of postoperative quality of life scores between the two groups.

Group		Dual-channel anastomosis group	Tubular gastroesophageal anastomosis group	Z value	P value
Cases		50	49
Somatic symptoms	Esophageal reflux scale	2.8 (2.3, 4.0)	4.8 (3.8, 5.0)	3.489	< 0.001
	Abdominal pain scale	2.0 (1.3, 3.0)	1.7 (1.3, 2.3)	0.358	0.72
	Eating distress subscale	2.7 (1.7, 3.0)	3.3 (2.7, 4.0)	3.393	0.001
	Digestive dysfunction scale	3.0 (2.5, 3.8)	2.8 (2.0, 3.8)	0.79	0.43
	Diarrhea subscale	1.3 (13, 1.7)	1.3 (13, 1.3)	0.143	0.886
	Constipation subscale	1.3 (1.3, 1.3)	1.3 (1.3, 1.3)	2.004	0.045
	Dumping scale	1.3 (1.3, 13)	3 (1.3, 1.3)	0.802	0.422
	Total symptom scale	2.3 (1.7, 2.7)	2.5 (2.2, 2.9)	2.243	0.025
Other outcome indicators	Increased anal exhaust	3.5 (2.0, 5.0)	3.0 (2.0, 4.0)	2.345	0.019
	Loose stool	2.0 (1.0, 2.0)	2.0 (2.0, 2.0)	2.397	0.017
Living conditions	Changes in body mass	13.7 (6.3, 18.6)	12.9 (8.7, 16.5)	0.042	0.967
	Food intake per meal	6.0 (4.0, 6.0)	5.0 (4.0, 6.0)	1.924	0.054
	Necessity of additional meals and meal quality	5.0 (3.0, 5.0)	5.0 (5.0, 5.0)	1.488	0.137
	Meal quality quantity scale	4.3 (3.7, 4.3)	4.0 (3.3, 4.3)	2.666	0.008
Quality of life	Working ability	2.0 (1.0, 2.0)	2.0 (1.0, 2.0)	1.362	0.173
	Dissatisfied with symptoms	2.0 (1.0, 3.0)	2.0 (2.0, 3.0)	2.127	0.033
	Discontent with dining	2.0 (1.0, 2.0)	2.0 (2.0, 3.0)	3.976	< 0.001
	Dissatisfied with work	1.0 (1.0, 2.0)	2.0 (1.0, 20)	2.279	0.023
	Scale of dissatisfaction	1.7 (13, 2.0)	2.0 (2.0, 2.3)	3.95	< 0.001
	Total measurement of physical health	83.8 (77.5, 88.8)	82.5 (77.5, 88.8)	1.702	0.089
	Overall measurement of mental health	93.8 (87.5, 100.0)	91.7 (83.3, 100.0)	0.412	0.68

Comparison of postoperative long-term complications

At 1 year after surgery, reflux esophagitis was less severe in the double-channel anastomosis group than in the tubular gastroesophageal anastomosis group, and the difference was statistically significant (P < 0.05). There was no significant difference in the incidence of postoperative anastomotic stenosis, intestinal obstruction, or gastric emptying disorder between the two groups (P > 0.05), as shown in Table 4. In the double-channel anastomosis group, one patient with a small intestinal obstruction was treated via surgery. In the double-channel anastomosis group and the tubular gastroesophageal anastomosis group, 3 and 7 patients with anastomotic stenosis, respectively, had endoscopic anastomotic dilation. The other patients received treatment based on their symptoms. Both groups of patients with long-term complications had a good prognosis after treatment.

Table 4 Comparison of long-term postoperative complications in patients with upper gastric adenocarcinoma, n (%).

Group	Cases	Reflux esophagitis					Anastomotic stenosis	Intestinal obstruction	Delayed gastric emptying
		Total	A	B	C	D
Dual channel matching group	50	2 (4.0)	2 (4.0)	0	0	0	6 (12.0)	1 (2.0)	0
Tubular gastroesophageal anastomosis group	49	13 (26.5)	6 (12.2)	5 (10.2)	1 (2.0)	1 (2.0)	12 (24.5)	0	2 (4.1)
Statistical value		χ2 = 13.507		Z = 3.177			χ2 = 2.595	χ2 < 0.001	χ2 = 0.531
P value		0.009		0.001			0.107	> 0.999	0.466

Changes in postoperative nutrition-related indexes

There were no significant differences in the levels of hemoglobin, serum ALB, or total serum protein between the two groups at any time point after surgery (P > 0.05). From 1 to 12 months after the operation, the hemoglobin and serum total protein levels of patients in the tubular gastroesophageal anastomosis group tended to increase. In the double-channel anastomosis group, the above indices showed an increasing trend at 1 to 6 months after the operation, and the serum ALB and total protein concentrations showed a slight decreasing trend at 6 to 12 months after the operation.

DISCUSSION

Reconstruction of the digestive tract after radical resection of proximal gastric cancer has been a hot topic for clinicians[19]. In the past, Roux-en-Y anastomosis was the surgeon's first choice for total gastrectomy, but patients were prone to malnutrition after this procedure. Although traditional proximal gastrectomy with residual gastroesophageal anastomosis preserves the distal stomach and can improve the nutritional status to some extent, the residual stomach of patients lacks control of the cardia, and reflux is prone to occur after surgery, which affects quality of life[20]. A number of studies have shown that, compared with traditional residual gastroesophageal anastomosis, tubular gastroesophageal anastomosis and double-channel anastomosis have precise antireflux effects and better quality of life and nutritional status. However, in terms of the antireflux effect, postoperative nutritional status, and quality of life, which operation (tubular gastroesophageal anastomosis or double-channel anastomosis) is more ideal is still controversial[21-23]. In the evaluation of digestive tract reconstruction after proximal gastrectomy, the antireflux effect is an important index[24].

This study is the first to report the use of tubular gastroesophagostomy for the treatment of early proximal gastric cancer[25]. This procedure reduces the possibility of esophageal reflux by cutting the residual stomach into a tubular stomach, making it similar to the gastric fundus structure, which can temporarily store gastric juice and reduce gastric acid secretion. Another study[26] showed that 23.3% of patients with tubular gastroesophageal anastomosis developed reflux esophagitis. One study[27] reported that 30% of patients who underwent proximal gastrectomy with tubular gastric anastomosis developed reflux symptoms, but the symptoms were mild. Another study[28] showed that the incidence of reflux symptoms after tubular gastroesophageal anastomosis was 14%. According to this study, 26.4% of patients in the tubular gastroesophageal anastomosis group who underwent gastroscopy one year after surgery had reflux esophagitis. Among these patients, 14.2% had reflux esophagitis of Los Angeles grade B or higher, which was the same as that reported in previous studies[29].

The aim of this study was to systematically evaluate the quality of life of patients after proximal gastrectomy with double-channel anastomosis and tubular gastroesophageal anastomosis[30]. Compared with previous studies, PSAS-45, designed by the Japan Post-Gastrectomy Syndrome Working Group, was comprehensively used in this study to evaluate the postoperative quality of life of patients in the proximal gastrectomy double-channel anastomosis and tubular gastroesophageal anastomosis groups[31]. This scale is the only comprehensive questionnaire that can be used to evaluate patients after different gastrectomy or reconstruction operations. According to the study's findings, the physical symptoms of esophageal reflux in the double-channel anastomosis group were less severe one year after surgery than those in the tubular gastroesophageal anastomosis group, and the majority of the symptoms were manageable with conservative treatment[32]. In addition, the degree of eating discomfort was less severe. In terms of postoperative quality of life, the satisfaction with daily life in the double-channel anastomosis group was better than that in the tubular gastroesophageal anastomosis group[33]. During the follow-up period, the authors found that esophageal reflux and discomfort after eating had a great impact on the lives of patients, and dual-channel anastomosis effectively reduced the occurrence of these symptoms, which was the same as the conclusion of previous studies[34-36]. These results indicate that the overall postoperative quality of life of patients in the double-channel anastomosis group was greater than that in the tubular gastroesophageal anastomosis group.

Postoperative nutritional status is also an important factor in the selection of proximal gastrectomy for gastrointestinal reconstruction[37]. The gastroduodenal channel was kept open with the tubular gastroesophageal anastomosis, and the physiological and anatomical structures of the stomach were mostly kept intact. Moreover, the pepsinogen and intrinsic factor secreted by the residual stomach can also promote the digestion and absorption of food. The preserved residual stomach can help move and mix food and bile, and some of the food can travel straight into the jejunum[38]. This can help with the slow emptying or sticking of the stomach that occurs after a vagotomy. Theoretically, both methods can improve the postoperative nutritional status of patients. In this study, hemoglobin, serum ALB, and total serum protein in both groups recovered to higher levels 1 year after surgery. In addition, postoperative gastrointestinal angiography revealed that 33.3% (8/24) of patients in the double-channel anastomosis group underwent single-channel angiography. According to previous studies[39-41], in some patients the food directly entered the jejunum after surgery without entering the residual stomach, which may lead to insufficient absorption of food nutrients. One year after surgery, the patients in the double-channel anastomosis group were more likely to have increased anal exhaust than were those in the tubular gastroesophageal anastomosis group. This may be because food moves more quickly into the jejunum, according to the quality of life assessment. These factors may be responsible for the slight decrease in the serum ALB and total protein concentrations at 6 to 12 months after surgery in patients who underwent double-channel anastomosis. The results of this study showed that there was no significant difference in postoperative nutritional status between patients who underwent proximal gastrectomy with tubular gastroesophageal anastomosis and those who underwent proximal gastrectomy with double-channel anastomosis.

Safe and feasible surgery and radical resection of tumors are prerequisites for treatment. All patients in this study underwent R0 excision, and postoperative pathological margins were negative. There was no significant difference in the number of lymph nodes dissected between the two groups. Compared with total gastrectomy, the number of lymph nodes examined was lower. Considering that distal lymph node metastasis of proximal gastric cancer is less common, it is still suitable for proximal gastrectomy of stages I and II gastric cancer patients. To improve the accuracy of lymph node staging, the lymph nodes should be completely cleaned, and the number of examined lymph nodes should be increased according to surgical requirements. The results of this study showed that the surgical conditions and perioperative complication rates of the two groups were similar, and the incidence of anastomotic leakage in the double-channel anastomosis group did not significantly increase due to the increase in anastomosis.

CONCLUSION

In summary, for stages I and II proximal gastric cancer, double-channel anastomosis is superior to tubular gastroesophageal anastomosis in terms of long-term quality of life and can significantly improve postoperative esophageal reflux symptoms and eating discomfort, with surgical safety not inferior to tubular gastroesophageal anastomosis. The results of this study can provide some guidance for surgeons in choosing surgical methods. However, considering that this was a single-center retrospective study with a limited number of included patients and insufficient follow-up time, further multicenter, large-sample prospective studies are needed for further verification of our findings.