Liu CC, Yang J, Yin G, Tian Z, Qin C. Kamikawa anastomosis in proximal gastrectomy for gastric cancer: A systematic review and meta-analysis. World J Gastrointest Surg 2025; 17(8): 107706 [DOI: 10.4240/wjgs.v17.i8.107706]
Corresponding Author of This Article
Chen Qin, MD, Department of Oncology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, No. 127 Siliu South Road, Qingdao 266000, Shandong Province, China. qinchenqinchen123@126.com
Research Domain of This Article
Surgery
Article-Type of This Article
Meta-Analysis
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Cheng-Cong Liu, Department of Gastrointestinal Surgery, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao 266000, Shandong Province, China
Jian Yang, Department of General Surgery, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao 266000, Shandong Province, China
Gang Yin, Department of Blood Transfusion, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao 266000, Shandong Province, China
Zhen Tian, Medical School, Nanjing University, Nanjing 266000, Jiangsu Province, China
Chen Qin, Department of Oncology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao 266000, Shandong Province, China
Author contributions: Liu CC, Yang J, Yin G, Tian Z, and Qin C designed the research; Liu CC and Yang J were responsible for data acquisition, analysis, and interpretation; Liu CC wrote the paper; Yang J, Yin G, Tian Z, and Qin C reviewed the manuscript.
Conflict-of-interest statement: The authors declare no conflicts of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chen Qin, MD, Department of Oncology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, No. 127 Siliu South Road, Qingdao 266000, Shandong Province, China. qinchenqinchen123@126.com
Received: March 28, 2025 Revised: May 22, 2025 Accepted: July 2, 2025 Published online: August 27, 2025 Processing time: 150 Days and 22.4 Hours
Abstract
BACKGROUND
Proximal gastrectomy (PG) for gastric cancer requires a delicate balance between oncological radicality and postoperative quality of life to mitigate reflux complications. Although the Kamikawa anastomosis has gained attention for its theoretical anti-reflux advantages, robust clinical evidence remains limited.
AIM
To comprehensively evaluate the efficacy, safety, and nutritional outcomes of the Kamikawa anastomosis in PG, thereby addressing a critical gap in surgical decision-making.
METHODS
Following PRISMA guidelines, we systematically searched PubMed, Embase, and the Cochrane Library for studies on Kamikawa anastomosis after PG. Data were pooled using fixed- or random-effects models based on heterogeneity levels (I2 statistics). The risk of bias was evaluated using Risk of Bias in Non-randomized Studies of Interventions. The protocol was prospectively registered in PROSPERO.
RESULTS
Of 106 screened studies, 20 involving 2291 patients were included. Most studies (85%) originated from Japan, with a mean patient age of 54-73 years and a male predominance (68.1%). Overall pooled incidence of 30-day postoperative complications was 9.9% [95% confidence interval (95%CI): 6.8-12.9], with major complications (Clavien-Dindo grade ≥ III) occurring in 6.1% (95%CI: 4.6-7.7). Anastomosis-related complications were observed in 7.2% of cases, comprising leakage 1.8% (95%CI: 1.1-2.4), stenosis in 7.2% (95%CI: 5.8-8.5), and bleeding in 0.7% (95%CI: 0.1-1.2). Pooled incidence of reflux esophagitis was 4% (95%CI: 2.7-5.3) for all LA grades at 12-month follow-up, with 28.3% (95%CI: 14.7-41.9) of patients requiring regular proton pump inhibitor use. Operative outcomes demonstrated a pooled mean operative time of 349.5 minutes (95%CI: 331-380), estimated blood loss of 351.5 mL (95%CI: 264-495), and postoperative hospital stay of 12.3 days (95%CI: 11.5-13.1). Nutritional outcomes revealed 11.4% (95%CI: 10.6-12.2) body weight loss at one year. Comparative analyses showed equivalent safety profiles between the Kamikawa anastomosis and double-tract reconstruction but longer operative times (P < 0.001) compared with total gastrectomy.
CONCLUSION
These findings underscore the clinical viability of the Kamikawa anastomosis following PG, demonstrating favorable anti-reflux efficacy, acceptable incidence of anastomotic strictures, and preservation of nutritional status.
Core Tip: This systematic review and meta-analysis evaluates the efficacy, safety, and nutritional outcomes of Kamikawa anastomosis following proximal gastrectomy for gastric cancer. Our findings suggest that Kamikawa anastomosis offers favorable anti-reflux benefits with a low incidence of anastomotic complications, including leakage and stenosis. The procedure is associated with acceptable postoperative outcomes, although it requires longer operative times compared to total gastrectomy. Despite some nutritional loss, the overall clinical profile supports its viability as an option for proximal gastrectomy, addressing a significant gap in surgical decision-making for gastric cancer.
Citation: Liu CC, Yang J, Yin G, Tian Z, Qin C. Kamikawa anastomosis in proximal gastrectomy for gastric cancer: A systematic review and meta-analysis. World J Gastrointest Surg 2025; 17(8): 107706
Proximal gastrectomy (PG) has emerged as a function-preserving alternative to total gastrectomy (TG) for proximal gastric cancer, with the aim of maintaining physiological digestive continuity and nutritional status[1-4]. However, adoption of the procedure has been hindered by the persistent challenge of postoperative gastroesophageal reflux, which occurs in 15%-30% of cases following conventional reconstruction methods[5-7]. This complication not only significantly affects patients' quality of life (QoL) but may also lead to long-term sequelae such as reflux esophagitis, Barrett's esophagus, and even metachronous esophageal carcinoma[1,6,8].
Esophagogastrostomy (EG), while offering the advantages of surgical simplicity and physiological alignment, is associated with a significant risk of severe reflux esophagitis postoperatively, leading to substantial deterioration in patients' QoL[9-12]. Alternative reconstruction techniques, including jejunal interposition (JI)[13], jejunal pouch interposition (JPI)[14], and double-tract reconstruction (DTR)[6], have demonstrated improved efficacy in reflux prevention by maintaining an appropriate distance between the esophagus and gastric remnant. However, these procedures have limitations, such as increased surgical complexity due to additional anastomoses, potential passage obstruction, and challenges in endoscopic surveillance of the gastric remnant[15-17]. These limitations have spurred the development of alternative techniques, among which Kamikawa anastomosis has gained increasing attention.
Kamikawa anastomosis, also known as the double-flap technique, represents an anti-reflux procedure utilized in EG following PG[18]. First described in 1998, utilizes a multi-stage procedure demanding advanced manual suturing skills instead of stapler devices. Key steps include fashioning a double H-shaped flap from the seromuscular layer, securing the junction between the distal esophagus and gastric remnant, and performing meticulous anastomosis followed by flap closure[19]. Significantly, the distal esophagus and anastomosis are subsequently enveloped within the gastric remnant's submucosa, shielded by a double-flap valve designed to prevent reflux[19]. Despite these theoretical advantages, the clinical evidence supporting Kamikawa anastomosis remains fragmented and inconclusive. Current literature primarily consists of single-center retrospective studies with limited sample sizes (typically < 100 cases) and heterogeneous outcome reporting. Although some studies report promising results with reflux rates as low as 5%-10%, others have raised concerns about technical complexity and potential complications, particularly anastomotic strictures. Furthermore, data on long-term outcomes, including nutritional status, QoL, and oncological safety, are limited. The existing systematic reviews on PG reconstruction techniques have predominantly focused on conventional methods such as DTR and JI, leaving a critical gap in the comprehensive evaluation of the Kamikawa anastomosis[13,17]. In their meta-analysis, Shaibu et al[20] demonstrated that only 4 of 27 included studies evaluated outcomes of the Kamikawa anastomosis, underscoring the importance of multicenter prospective trials. The current inability to perform pooled safety analyses persists as a critical barrier to the development of clinical guideline, particularly regarding anastomotic complications and long-term functional outcomes that require standardized multi-institutional tracking.
This study represents the first PRISMA-compliant systematic review and pooled analysis specifically evaluating the Kamikawa anastomosis in PG. By synthesizing available evidence from comparative and non-comparative studies, we aimed to provide a comprehensive assessment of its efficacy in reflux prevention and safety profile. Our analysis addressed several critical questions: (1) What is the true incidence of reflux esophagitis and anastomotic stenosis following Kamikawa anastomosis? (2) How does its complication profile compare with that of conventional reconstruction methods? And (3) What are the long-term functional and nutritional outcomes? The findings of this review are expected to inform clinical practice, guide surgical decision-making, and identify key areas for future research in the evolving field of function-preserving gastric cancer surgery.
MATERIALS AND METHODS
This systematic review and meta-analysis was performed and reported following the PRISMA Statement[21] and AMSTAR-2[22] guidelines (Supplementary material). The protocol was prospectively registered with PROSPERO on January 29, 2025.
Data sources and search strategy
A comprehensive literature search was conducted through December 31, 2024, across PubMed, EMBASE, and the Cochrane Library. The search strategy employed a combination of the following terms: (“proximal gastrectomy” OR “proximal gastric cancer” OR “adenocarcinoma of esophagogastric junction” OR “AEG”) AND (“double flap technique” OR “Kamikawa”). To focus on contemporary evidence, the inclusion criteria were restricted to articles published between January 1, 2015, and December 31, 2024. Only the studies published in English were included. Manual cross-checking of the reference lists in the retrieved articles was performed to identify relevant additional studies. References were managed using EndNote software (version X9; Clarivate), and duplicates were excluded manually. Because this analysis exclusively utilized publicly available data, ethical approval and patient consent were not required.
Study selection
Two researchers independently evaluated the retrieved studies. An initial screening of titles and abstracts excluded non-relevant publications, including case reports, letters, reviews, and unrelated articles. Subsequently, the full-text articles were rigorously evaluated to confirm alignment with the inclusion criteria. Guided by the PICOS framework (population, intervention, comparator, outcome, study design), eligibility criteria were defined as follows: Population—patients diagnosed with proximal gastric cancer or adenocarcinoma of the esophagogastric junction (AEG); intervention—PG with Kamikawa anastomosis; outcomes—incidence of reflux esophagitis and anastomotic stenosis; study design—clinical trials or prospective/retrospective observational studies. The exclusion criteria were as follows: (1) Aample sizes below 10 patients; (2) Reviews, conference abstracts, commentaries, letters, or animal studies; (3) Non-English publications; (4) Pathological diagnoses of non-target malignancies (e.g., gastrointestinal stromal tumors); and (5) Insufficient data for quantitative synthesis.
Data extraction and outcome measures
Two researchers independently extracted data using standardized, piloted data extraction forms, recording: (1) Research background (first author’s surname, publication year, study design, country, cohort size); (2) Cohort demographics (mean age and sex distribution); (3) Surgical metrics (operative duration, intraoperative blood loss, anastomosis time, dissected lymph nodes); (4) Postoperative complications [early complications ≤ 30 days, Clavien-Dindo (CD) grade, anastomotic leakage/bleeding/ stenosis, reflux esophagitis, reflux symptoms, and 1-year proton pump inhibitor (PPI) use]; and (5) 1-year nutritional outcomes [percentage body weight loss (BWL)]. A third independent reviewer re-evaluated all data, with discrepancies resolved through consensus discussions to minimize bias and ensure reliability.
The primary outcome was defined as the reflux-related outcomes, while the secondary outcomes include surgical metrics, postoperative complications, and 1-year nutritional outcomes, among others. Reflux-related outcomes were evaluated based on both clinical symptoms and objective diagnostic methods, including gastrointestinal endoscopy. Gastrointestinal endoscopies were performed routinely for all cases in the study, typically within the first year post-surgery to assess for conditions such as reflux esophagitis, anastomotic stenosis, and other complications. The endoscopies were carried out by trained gastroenterologists and endoscopy specialists who were experienced in diagnosing esophageal and gastric conditions. Reflux esophagitis was graded using the Los Angeles Classification[23], which categorizes esophageal mucosal damage based on the severity of reflux.
Reconstruction with Kamikawa anastomosis
Key aspects of the Kamikawa anastomosis include: (1) Muscular flap formation: A gentian violet surgical marker was used to delineate an "I"-shaped template, typically 2.5 cm wide by 3.5 cm high, on the anterior gastric remnant wall. This marking was positioned roughly 1.5 cm inferior to the remnant's upper incisal margin, adjacent to the lesser curvature. The seromuscular flap's width was intended to match the esophageal diameter. Furthermore, the flap's superior border was oriented parallel to the gastric remnant's upper incisal margin; (2) Dissection: Carefully dissect between the submucosal layer and muscle layer to separate the muscular flap, being cautious to avoid damaging the submucosal vessels and mucosa; (3) Creating a mucosal window: A mucosal window is made at the lower edge of the muscular flap, with the width of the incision matching that of the esophagus; (4) Fixation: Traction is applied to the esophagus, and 3-4 sutures are used to fix the posterior wall of the stomach 5 cm from the esophageal remnant, connecting it to the upper edge of the muscular flap; (5) Posterior wall anastomosis: The entire thickness of the esophageal posterior wall is continuously sutured to the gastric mucosa and submucosa; (6) Anterior wall anastomosis: The anterior wall of the esophagus is sutured either in layers or through full thickness to the lower edge of the gastric wall at the remnant stomach opening; and (7) Suturing the muscular flap: The two sides of the muscular flap are sutured together and fixed to the esophagus. The upper and lower edges of the flap are sutured to the esophageal and gastric walls, forming a “Y” shape to cover the anastomosis, as illustrated by Yamashita et al[17], Kuroda et al[19], Wu et al[24], and Shoji et al[25]. After completing anastomosis reconstruction, an intraoperative endoscopic examination of the anastomosis was performed.
Quality assessment
The risk of bias for the included studies was appraised using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, which assesses the risk of bias across seven domains: Confounding factors, participant selection, intervention classification, deviations from intended protocols, missing data, outcome measurement, and selective reporting. Each domain was rated as “Low,” “Moderate,” “Serious,” “Critical,” or “No information”, with the highest risk level across domains defining a study’s overall bias classification. Two reviewers independently evaluated the study quality following the ROBINS-I guidelines, resolving discrepancies through third-author arbitration.
Statistical analysis
Statistical analyses were performed using R (v4.3.2)/RStudio (v4.2.2) and Open Meta Analyst (CEBM, Brown University). A random-effects model with 95% confidence intervals (95%CIs) was applied across all analyses, accounting for clinical heterogeneity, with pooled proportions for single-arm binary outcomes and mean difference values for continuous outcomes calculated using Restricted Maximum Likelihood estimation. Heterogeneity was quantified using Cochran’s Q test and I2 statistics, with I2 thresholds defined as follows: < 25% (negligible), 25-50% (moderate), and > 50% (substantial). Forest plots visualized study-specific and aggregated results, whereas subgroup analyses explored sources of heterogeneity. Publication bias was evaluated through funnel plot symmetry assessment and was statistically validated using the Egger’s test. Sensitivity analyses (leave-one-out method) were performed for outcomes with significant heterogeneity (I2 > 50%) to evaluate the robustness by iteratively excluding individual studies.
RESULTS
Study selection
Following duplicate removal, our search identified 106 studies. Of these, 41 underwent full-text evaluation (see Figure 1). Ultimately, 20 studies fulfilled eligibility criteria for inclusion in the quantitative synthesis[15,18,19,23-39]. The initial agreement between the two investigators for study selection was high (κ = 0.96), and discrepancies were adjudicated via discussion involving a third investigator.
Figure 1 Flow chart of the search for eligible studies.
Study characteristics
This meta-analysis included 20 studies with 2291 participants[15,18,19,26-28,30-44]. Table 1 describes the main study characteristics, and Table 2 presents the outcomes. All studies were published between 2016 and 2024. Sample size for each study was between 12-546. All the included studies used a retrospective cohort design, with the majority (n = 17) conducted in Japan[18,19,23,25-29,31-39]. The remaining three studies were distributed as follows: Two in China[24,30] and one in Korea[15]. Mean age of patients at diagnosis was between 54-73 years. Distribution of patients according to sex was 1195 (68.1%) males and 561 (31.9%) females.
Among the 20 non-randomized studies included in our systematic review, the methodological quality assessment using the ROBINS-I tool revealed the following distribution: Two studies[34,36] were classified as having a "Low" risk of bias, eight studies[18,19,25,29,31,33,35,39] demonstrated a "Moderate" risk of bias, and ten studies[15,23,24,26-28,30,32,37,38] were assessed as having a "Serious" risk of bias. Primary methodological limitations contributing to the increased risk of bias were the absence of appropriate control groups and potential presence of unmeasured confounders, which may have influenced the observed outcomes. The comprehensive risk of bias assessment for each individual study is presented in Figure 2, which provides a detailed overview of the methodological quality across all the included studies.
Figure 2 Risk of bias plot following the Risk of Bias in Non-randomized Studies of Interventions tool for quality assessment.
Surgical parameters
The pooled analysis demonstrated that laparoscopic PG (LPG) with Kamikawa anastomosis was associated with a mean operative time of 317.8 min (95%CI: 274.1-361.4; I² = 99.4%; Figure 3A)[15,18,19,23-25,30,32,34-39]. Mean anastomosis time was 93.1 min (95%CI: 83.7-102.4; I2 = 69.8%; Figure 3B), suggesting variability in surgical proficiency, with a steep initial learning curve that improved with experience[15,19,27,30,34,36,37]. Intraoperative blood loss was 55.9 mL (95%CI: 43.9-67.9; I2 = 99.3%; Figure 3C)[15,18,27,28,30,32,34-39], although studies have consistently reported minimal bleeding, potentially reflecting the technical precision of the Kamikawa method. Additionally, mean number of lymph nodes harvested was 33.3 (95%CI: 31-35.7; I2 = 86.4%; Figure 3D)[15,24,31,34,35], indicating that lymphadenectomy completeness may depend on the surgeon’s expertise rather than on the anastomotic technique itself (Table 2).
Figure 3 Forest plot of surgical parameters.
A: Operative time; B: Anastomosis time; C: Surgical bleeding; D: Number of lymph nodes harvested.
Postoperative complications
Pooled incidence of early postoperative complications (within 30 days) was 9.9% (95%CI: 6.8-12.9; I2 = 76.6%; Figure 4A)[15,18,26-28,30-39], including a 6.1% incidence of severe complications (CD grade ≥ III; 95%CI: 4.6-7.7; I2 = 0%; Figure 4B)[15,28,35,38-39]. In contrast, anastomosis-related complications exhibited no significant heterogeneity: The incidence of anastomotic leakage was 1.8% (95%CI: 1.1-2.4; I2 = 0%; Figure 4C)[15,18,26-28,31,34-39], anastomotic bleeding was 0.7% (95%CI: 0.1-1.2; I2 = 0%; Figure 4D)[18,19,26-28,34-36,39], and anastomotic stenosis was 7.2% (95%CI: 5.8-8.5; I2 = 0%; Figure 4E)[15,18,19,26,28,30,31,33,35-39]. Similarly, reflux-related outcomes showed minimal heterogeneity, with reflux esophagitis [4% (95%CI: 2.7-5.3; I2 = 0%); Figure 5A][15,27,28,31-39], subjective reflux symptoms [9.6% (95%CI: 3-16.2; I2 = 88.1%); Figure 5B][24,34,35], and postoperative PPI intake [28.3% (95%CI: 14.7-41.9; I2 = 96.5%); Figure 5C][15,18,28,29,34,35], demonstrating the anti-reflux efficacy of Kamikawa anastomosis. The high heterogeneity in early complications likely reflects variability in the study populations or surgical expertise, whereas consistency in other outcomes underscores the technical reliability of the Kamikawa method in mitigating specific postoperative risks (Table 3).
Figure 5 Forest plots of reflux-related complications and nutritional status at one year postoperatively.
A: Reflux esophagitis; B: Subjective reflux symptoms; C: Proton pump inhibitor intake; D: Body weight loss.
Table 3 Short- and long-term outcomes of Kamikawa.
The mean percentage of BWL at 1 year postoperatively was 11.4% (95%CI: 10.6-12.2; I2 = 76.86%; Figure 5D)[15,18,27,31,35,37-39], suggesting substantial variability in nutritional outcomes across studies (Table 3).
Subgroup analysis and sensitivity analysis
To explore potential sources of heterogeneity in the incidence of early postoperative complications, subgroup analyses were conducted based on the following factors: Country of origin, year of publication (stratified into 2016-2020 and 2021-2024), and sample size (≤ 30 vs > 30; Figure 6A-C). Subgroup analyses confirmed that none of these factors significantly influenced the incidence of early complications (P > 0.05), suggesting that the observed heterogeneity may be attributable to other unmeasured variables, such as surgical techniques or patient-specific characteristics. Moreover, a leave-one-out approach was applied for the sensitivity analysis to evaluate the effect of a single study on early postoperative complications with a high degree of heterogeneity (Figure 6D). However, the omission of a single study was not sufficient to considerably reduce the heterogeneity.
Figure 6 Subgroup and sensitivity analyses of heterogeneity in early postoperative complications after Kamikawa anastomosis.
A-C: Subgroup analyses evaluated potential sources of heterogeneity in the pooled incidence of early postoperative complications. Stratified variables included country of origin (A), publication year (B), and sample size (C); D: Sensitivity analysis employed a leave-one-out approach to assess the influence of individual studies on high heterogeneity.
Publication bias assessment
Visual analysis of the funnel plot for outcomes of early postoperative complications, reflux esophagitis, and anastomotic stenosis showed slight asymmetry, suggesting a small study effect (Figure 7). However, the Egger’s regression test did not confirm publication bias (P = 0.38, P = 0.22, and P = 0.84, respectively).
Comparative analysis between Kamikawa and DTR groups demonstrated no statistically significant differences in surgical parameters and postoperative complications. Specifically, the operative time (SMD = 0.10, 95%CI: -0.26 to 0.46, P = 0.993, I2 = 0%, Figure 8A), anastomosis time (SMD = 0.76, 95%CI: 0.13-1.39, P = 0.132, I2 = 55.8%, Figure 8B), and intraoperative blood loss (SMD = -0.2, 95%CI: -0.56 to 0.15, P = 0.284, I2 = 20.6%, Figure 8C) were comparable between the two groups. Similarly, the incidence of early postoperative complications (RR = 0.70, 95%CI: 0.37-1.33, P = 0.679, I2 = 0%, Figure 8D) and late complications, including reflux esophagitis (RR = 0.46, 95%CI: 0.13-1.69, P = 0.397, I2 = 0%, Figure 8E) and anastomotic stenosis (RR = 0.83, 95%CI: 0.24-0.18, P = 2.91, I2 = 72.2%, Figure 8F), showed no significant intergroup disparities (P > 0.05). Furthermore, the postoperative PPI intake rates were comparable (RR = 0.82, 95%CI: 0.46-1.43, P = 0.525, I2 = 0%, Figure 8G).
Figure 8 Forest plots between the laparoscopic proximal gastrectomy-Kamikawa group and the laparoscopic proximal gastrectomy-double-tract construction group.
A: Operative time; B: Anastomosis time; C: Surgical bleeding; D: Early complications; E: Reflux esophagitis; F: Anastomotic stenosis; G: Proton pump inhibitor intake.
LPG with Kamikawa vs laparoscopic TG with Roux-en-Y
Pooled analysis revealed that the Kamikawa group demonstrated significantly longer operative times (SMD = 0.60, 95%CI: 0.38-0.82, P < 0.0001, I2 = 95.3%, Figure 9A) and greater intraoperative blood loss (SMD = 0.38, 95%CI: 0.17-0.60, P < 0.0001, I2 = 89.5%, Figure 9B) than the laparoscopic TG (LTG) group, with substantial heterogeneity observed across studies. However, no statistically significant differences were identified between the two groups in terms of hospital stay duration (SMD = -0.32, 95%CI: -0.58 to -0.05, P = 0.351, I2 = 4.4%, Figure 9C), incidence of early postoperative complications (RR = 0.62, 95%CI: 0.36-1.07, P = 0.188, I2 = 35.0%, Figure 9D), or late complications, including reflux esophagitis (RR = 0.84, 95%CI: 0.24-3.02, P = 0.087, I2 = 54.4%, Figure 9E) and anastomotic stenosis (RR = 1.19, 95%CI: 0.44-3.26, P = 0.141, I2 = 48.9%, Figure 9F).
Figure 9 Forest plots between the laparoscopic proximal gastrectomy-Kamikawa group and the laparoscopic total gastrectomy group.
A: Operative time; B: Surgical bleeding; C: Hospital stay; D: Early complications; E: Reflux esophagitis; F: Anastomotic stenosis.
DISCUSSION
The present systematic review and pooled analysis, encompassing 20 studies and 1756 patients, provides a rigorous synthesis of evidence supporting Kamikawa anastomosis in PG for proximal gastric cancer or AEG. Our findings highlight the technical feasibility, favorable postoperative safety profile, and potential advantages of the Kamikawa anastomosis in mitigating reflux-related complications, while also revealing critical areas of heterogeneity and methodological limitations. These results align with emerging trends in gastric cancer surgery, where organ-preserving techniques are increasingly prioritized to balance oncological efficacy with functional outcomes. By contextualizing our findings within recent literature and addressing unresolved controversies, this discussion advances the clinical and academic discourse on reconstructive strategies after PG.
The Kamikawa anastomosis demonstrates a unique balance between technical complexity and procedural reliability. The pooled operative time of 317.8 minutes and anastomosis time of 55.9 minutes, although indicative of a steep learning curve, are comparable to values reported for other complex reconstructions, such as DTR[8]. A 2018 multicenter Japanese study by Kuroda et al[18] reported similar operative times for the Kamikawa anastomosis (median: 298 minutes), underscoring the consistency of our findings with contemporary data from high-volume centers. However, the high heterogeneity in these metrics (I2 > 99%)—mirrored in lymph node harvest (33.3 nodes; I2 = 86.4%)—suggests that surgical proficiency remains a pivotal determinant of outcomes. This aligns with recent critiques by Wu et al[40] who emphasized that the technical demands of the Kamikawa anastomosis necessitate standardized training programs, particularly as adoption expands beyond specialized institutions in Japan, where 85% of the included studies originated[41].
Reflux esophagitis, a pivotal determinant of long-term postoperative QoL after PG[1,5,8,38,42], is a key challenge in standardizing post-PG reconstruction. Reflux esophagitis may lead to chronic severe symptoms (regurgitation, heartburn, and cough)[5,43,44], underscoring the clinical significance of the Kamikawa anastomosis. The principal advantage of the Kamikawa anastomosis lies in effectively preventing reflux without requiring adjunctive acid-suppressive medications (e.g., PPIs/H2 blockers), thereby reducing long-term medication dependence and costs[18]. Postoperative outcomes reinforce the anti-reflux efficacy of the Kamikawa anastomosis, a cornerstone of its clinical appeal. Reflux esophagitis has been documented following simple EG performed without anti-reflux measures, occurring in 9.1% to 35.3% of patients. Notably, clinically significant reflux rates persist even with procedures specifically designed to prevent it: JI, JPI, and DTR exhibit incidences of 0%-33.3%, 8.3%-27.8%, and 0%-25%, respectively[20,21,45]. While certain modified EG approaches (e.g., fundoplication) achieve reflux esophagitis rates of < 10%[46,47], others fail despite anti-reflux modifications[48,49]. In this review, the pooled results showed that the Kamikawa anastomosis was successful in preventing reflux esophagitis (grade B or higher) with an incidence of 4.9%. In an analysis of up to 464 patients by Kuroda et al[18], the incidence of reflux esophagitis was 10.6% for all grades and 6.0% for grade B or higher esophagitis, which is considered to be closer to the “real-world data”.
Anastomotic stenosis predominates as the most clinically significant anastomosis-related complications following Kamikawa reconstruction, necessitating vigilant postoperative surveillance, whereas leakage remains rare owing to the inherent design of submucosal anastomotic placement reinforced by a seromuscular double-flap. Current clinical practice favors circular staplers for esophagojejunostomy; however, stapled anastomosis demonstrates a higher incidence of stenosis than manual suturing, as evidenced by comparative cohort studies[50,51]. The hand-sewn suturing technique employed in Kamikawa EG imparts pliability to the anastomosis, potentially mitigating stenosis development. Consequently, the procedure's characteristically low anastomotic stricture rate may be attributable to this manual suturing approach rather than the inherent design of the reconstruction itself. In a study by Shibasaki et al[26], a greater number of stitches were used in patients with anastomotic stenosis than in those who did not develop anastomotic stenosis, suggesting that the anastomotic site might be too tightly closed with an excessive number of stitches. In addition, inadequate preparation of the seromuscular flap presents risks of flap ischemia and subsequent stomal stenosis. In this review, the pooled rate of anastomotic stenosis after the Kamikawa procedure was 8.3%. Shaibu et al[20] reported that the incidence of anastomotic stenosis was 0%-40% (13.0% in total) for EG, 0%-4.65% (3.5% in total) for DT, and 0%-64.3% (11.3% in total) for JI. Yamashita et al[52] reported that the incidence of anastomotic stenosis was 2.8% in mSOFY. In addition, the incidence of anastomotic stricture requiring endoscopic balloon dilatation in the rD-FLAP study was 5.5%, and if limited to the Kamikawa anastomosis, the incidence was as high as 13.4%[18]. In the lD-FLAP study, the incidence of anastomotic stenosis requiring endoscopic balloon dilatation was 5.3%[33]. According to these reports, the incidence of anastomotic stricture in the present study is considered acceptable, although more effort is needed to reduce the incidence. Moreover, laparoscopic performance of the Kamikawa procedure has been documented in several reports[15,53]. This minimally invasive approach potentially enhances postoperative outcomes. However, the technique imposes notable technical demands, primarily due to restricted instrument articulation. Consequently, a significant learning curve correlates with anastomosis-related complication rates following laparoscopic Kamikawa reconstruction. Surgeons undertaking this method therefore require advanced proficiency in laparoscopic suturing techniques. Robotic surgical systems, with their inherent technical advantages in intracorporeal suturing, including wristed instrument articulation, tremor filtration, motion scaling, and stereoscopic visualization, may enhance the procedural reproducibility of the Kamikawa anastomosis for reflux esophagitis prevention compared to conventional laparoscopic or open approaches[38,40]. In the studies included in our analysis, all robotic gastrectomies were performed using the Da Vinci Surgical System. This potential superiority is further supported by comparative learning curve analyses: Robotic gastrectomy achieved proficiency in approximately 20 cases, in contrast to the 40-60 case requirement for laparoscopic mastery[30].
Weight loss after gastrectomy is associated with deterioration in QoL[54] and indicates a poor long-term prognosis in patients with gastric cancer[15,55]. In this study, the Kamikawa group showed a decrease in weight at 1 year postoperatively compared with the preoperative period. Although the Kamikawa anastomosis may preserve nutritional status by maintaining gastric reservoir function and mitigating reflux-related eating difficulties, the high heterogeneity in BWL likely reflects differences in patient demographics (e.g., baseline body mass index and dietary adherence), follow-up duration, or variations in postoperative nutritional management protocols. These findings highlight the need for standardized nutritional interventions and long-term monitoring to clarify the relationship between Kamikawa anastomosis and weight preservation in patients undergoing proximal gastrectomy. Consistent with prior evidence, the Kamikawa groups demonstrated reduced postoperative weight loss compared with the DTR group. Given comparable stomach preservation rates (> 50% residual volume) between groups, nutritional outcome divergence may originate from distinct alimentary transit patterns—specifically, differential flow volume through gastric remnants vs duodenal pathways. Park et al[6] quantified post-DTR gastroduodenal transit dynamics through routine 3-month gastric emptying scans, demonstrating delayed clearance (mean, 164.3 minutes) and a 2:3 stomach-to-jejunum flow ratio. Suboptimal alimentary routing following DTR, characterized by ingested contents bypassing gastric/duodenal processing via direct jejunal entry, may compromise the therapeutic efficacy when inadequate gastric remnant transit persists[56,57]. However, the superior nutritional outcomes observed in the Kamikawa cohort compared to the DTR group necessitate cautious interpretation. Validation requires extended follow-up due to potential confounding from administered oral iron, vitamin B12 injections, and limitations inherent to the study's constrained annual observation period. Additionally, the Global Leadership Initiative on Malnutrition (GLIM) criteria, which combines phenotypic and etiological factors for a more comprehensive evaluation of malnutrition, could offer a more standardized approach for assessing nutritional outcomes[58,59]. In future studies, incorporating the GLIM may provide additional depth and precision in understanding the nutritional status of patients, thereby enhancing the validity of our findings and potentially identifying at-risk individuals more accurately.
Comparative analyses of LPG-DTR and LTG have provided clinically important insights. The similarities between the Kamikawa anastomosis and DTR in terms of operative parameters, complications, and PPI challenges the traditional preference for Roux-en-Y configuration in DTR to mitigate reflux. In contrast to earlier retrospective studies favoring the Kamikawa method for long-term nutritional outcomes, we found no difference in the reflux severity scores between the two techniques[15,27,32,60]. This discrepancy may reflect evolving surgical expertise, as Kamikawa’s adoption increases. The inherent complexity of double tract anastomosis, involving the potential creation of multiple anastomotic stomas, presents an elevated risk of postoperative leakage. This technique is also associated with increased procedural costs due to the requirement for more linear cutter staplers. Supporting this, Yu et al[15] reported that DTR procedures utilized an average of 6.86 staplers, significantly exceeding the 3.39 staplers typically employed in Kamikawa procedures. Furthermore, when contrasted with TG, the Kamikawa approach demonstrated longer operative durations and greater intraoperative blood loss. However, these disadvantages were offset by similar lengths of hospital stay and comparable overall complication rates. Specifically, mean operative time was notably extended in the LPG-Kamikawa group relative to the LTG group. This disparity is likely attributable to the technically demanding valvuloplasty integral to the LPG-Kamikawa technique. This procedure requires masterful intracorporeal suturing, although standardization of the procedure could shorten the operative time for treatments involving the Kamikawa anastomosis. The high heterogeneity in operative time and blood loss may reflect the variability in surgical techniques, patient selection, or perioperative management across studies, necessitating cautious interpretation of these findings. These results suggest that although the Kamikawa anastomosis may entail a longer operation time and greater intraoperative blood loss than LTG, it does not compromise short-term recovery or long-term complication rates in patients undergoing gastric cancer resection.
Recent studies have reported the outcomes of the modified Kamikawa anastomosis technique[27,34], which has been proposed by other researchers and demonstrated to be a safe and feasible treatment in LPG. This modified technique ensures excellent postoperative anti-reflux effects and nutritional status, while also offering advantages in postoperative recovery and QoL when compared with double tract anastomosis. The modifications made to the traditional Kamikawa technique include: (1) Separation and suspension of the left extrahepatic lobe: Reduces obstruction, improves visualization, and avoids liver trauma without requiring additional instruments; (2) Adjustment of the seromuscular flap width: Matches the typical 2.5-3 cm width of the esophagus, reducing anastomotic stenosis risk; (3) Improved anastomotic stoma fixation: Fixes the posterior esophageal stump and anastomotic stoma with two interrupted sutures for easier subsequent suturing and reduced stenosis risk; (4) Use of continuous sutures: Simplifies the procedure and shortens the operation time by replacing interrupted sutures; (5) Improved blood supply to the seromuscular flap: Positions the flap near the gastric remnant's lesser curvature for better blood flow and enhanced anti-reflux effect; and (6) Larger pseudofornix: Creates a larger pseudofornix for better anti-reflux outcomes, with careful tension control to prevent stenosis. These modifications make the technique more feasible and effective, reducing the operative time by approximately half compared with the traditional approach. We believe that these improvements will contribute to better postoperative outcomes and highlight the potential of the modified Kamikawa anastomosis as a valuable option in LPG.
The methodological limitations of the included studies highlight the strengths of our conclusions. The predominance of retrospective, single-arm designs, particularly in Japan, introduces selection bias and limits external validity. Only two studies were rated as having a low risk of bias, primarily due to confounding by unmeasured variables such as surgeon experience or tumor biology. Furthermore, the lack of long-term survival and quality-of-life data precludes assessment of oncological adequacy and functional superiority of the Kamikawa anastomosis. Publication bias, although not statistically confirmed, remains a concern given the slight funnel plot asymmetry for early complications, potentially skewing outcomes toward favorable results from high-volume centers. To address these limitations, future studies must prioritize prospective randomized trials comparing the Kamikawa technique with DTR and TG with standardized endpoints, including reflux-specific quality-of-life metrics (e.g., Visick scores) and nutritional biomarkers (e.g., albumin and prealbumin levels). The ongoing randomized clinical trial (NCT05892289) evaluating the Kamikawa anastomosis against DTR with 5-year survival outcomes represents a critical step in this direction. Additionally, centralized surgical training initiatives modeled on the Japanese Endoscopic Surgical Skill Qualification System could reduce technical variability and accelerate the learning curve.
CONCLUSION
This synthesis positions the Kamikawa anastomosis as a viable reconstructive option for PG, offering technical reproducibility to experienced surgeons and superior anti-reflux outcomes compared with conventional techniques. Although its learning curve and nutritional variability require further refinement through standardized protocols, the favorable safety profile of the procedure relative to DTR and TG-Roux-en-Y underscores its growing relevance in the era of function-preserving gastric cancer surgery. As the field moves toward personalized reconstruction strategies, the Kamikawa anastomosis warrants inclusion in the surgical armamentarium, pending validation through high-quality comparative studies and long-term functional assessments.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A, Grade B
Novelty: Grade A, Grade B
Creativity or Innovation: Grade A, Grade B
Scientific Significance: Grade A, Grade B
P-Reviewer: Nakaji K S-Editor: Lin C L-Editor: A P-Editor: Yu HG
Yuan Z, Cui H, Xu Q, Gao J, Liang W, Cao B, Lin X, Song L, Huang J, Zhao R, Li H, Yu Z, Du J, Wang S, Chen L, Cui J, Zhao Y, Wei B. Total versus proximal gastrectomy for proximal gastric cancer after neoadjuvant chemotherapy: a multicenter retrospective propensity score-matched cohort study.Int J Surg. 2024;110:1000-1007.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 8][Cited by in RCA: 8][Article Influence: 8.0][Reference Citation Analysis (0)]
Yang X, Zeng Z, Liao Z, Zhu C, Wang H, Wu H, Cao S, Liang W, Li X. Comparison of proximal gastrectomy and total gastrectomy in proximal gastric cancer: a meta-analysis of postoperative health condition using the PGSAS-45.BMC Cancer. 2024;24:1282.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 5][Reference Citation Analysis (0)]
Yamasaki M, Takiguchi S, Omori T, Hirao M, Imamura H, Fujitani K, Tamura S, Akamaru Y, Kishi K, Fujita J, Hirao T, Demura K, Matsuyama J, Takeno A, Ebisui C, Takachi K, Takayama O, Fukunaga H, Okada K, Adachi S, Fukuda S, Matsuura N, Saito T, Takahashi T, Kurokawa Y, Yano M, Eguchi H, Doki Y. Multicenter prospective trial of total gastrectomy versus proximal gastrectomy for upper third cT1 gastric cancer.Gastric Cancer. 2021;24:535-543.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 16][Cited by in RCA: 42][Article Influence: 10.5][Reference Citation Analysis (0)]
Park DJ, Han SU, Hyung WJ, Hwang SH, Hur H, Yang HK, Lee HJ, Kim HI, Kong SH, Kim YW, Lee HH, Kim BS, Park YK, Lee YJ, Ahn SH, Lee I, Suh YS, Park JH, Ahn S, Park YS, Kim HH. Effect of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction vs Total Gastrectomy on Hemoglobin Level and Vitamin B12 Supplementation in Upper-Third Early Gastric Cancer: A Randomized Clinical Trial.JAMA Netw Open. 2023;6:e2256004.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 44][Cited by in RCA: 46][Article Influence: 23.0][Reference Citation Analysis (0)]
Kunisaki C, Yoshida K, Yoshida M, Matsumoto S, Arigami T, Sugiyama Y, Seto Y, Akiyama Y, Oshio A, Nakada K. Effects of Proximal Gastrectomy and Various Clinical Factors on Postoperative Quality of Life for Upper-third Gastric Cancer Assessed using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45): A PGSAS NEXT Study.Ann Surg Oncol. 2022;29:3899-3908.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 25][Cited by in RCA: 22][Article Influence: 7.3][Reference Citation Analysis (0)]
Hipp J, Hillebrecht HC, Kalkum E, Klotz R, Kuvendjiska J, Martini V, Fichtner-Feigl S, Diener MK. Systematic review and meta-analysis comparing proximal gastrectomy with double-tract-reconstruction and total gastrectomy in gastric and gastroesophageal junction cancer patients: Still no sufficient evidence for clinical decision-making.Surgery. 2023;173:957-967.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 18][Reference Citation Analysis (0)]
Li B, Wang Y, Wu Z, Shan F, Li S, Jia Y, Miao R, Li Z, Xue K, Yan C, Li S, Ji J, Li Z. Safety and short-term outcomes of a modified valvuloplastic esophagogastrostomy versus gastric tube anastomosis after laparoscopy-assisted proximal gastrectomy: a retrospective cohort study.Surg Endosc. 2024;38:1523-1532.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 1][Cited by in RCA: 2][Article Influence: 2.0][Reference Citation Analysis (0)]
Zhu G, Jiao X, Zhou S, Zhu Q, Yu L, Sun Q, Li B, Fu H, Huang J, Lang W, Lang X, Zhai S, Xiong J, Fu Y, Liu C, Qu J. Can proximal gastrectomy with double-tract reconstruction replace total gastrectomy? a meta-analysis of randomized controlled trials and propensity score-matched studies.BMC Gastroenterol. 2024;24:230.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 5][Reference Citation Analysis (0)]
Yamamoto M, Omori T, Shinno N, Hara H, Fujii Y, Mukai Y, Sugase T, Takeoka T, Asukai K, Kanemura T, Hasegawa S, Akita H, Haraguchi N, Nishimura J, Wada H, Matsuda C, Yasui M, Miyata H, Ohue M. Laparoscopic Proximal Gastrectomy with Novel Valvuloplastic Esophagogastrostomy vs. Laparoscopic Total Gastrectomy for Stage I Gastric Cancer: a Propensity Score Matching Analysis.J Gastrointest Surg. 2022;26:2041-2049.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 1][Cited by in RCA: 8][Article Influence: 2.7][Reference Citation Analysis (0)]
Yamashita H, Toyota K, Kunisaki C, Seshimo A, Etoh T, Ogawa R, Baba H, Demura K, Kaida S, Oshio A, Nakada K. Current status of gastrectomy and reconstruction types for patients with proximal gastric cancer in Japan.Asian J Surg. 2023;46:4344-4351.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 8][Reference Citation Analysis (0)]
Kuroda S, Choda Y, Otsuka S, Ueyama S, Tanaka N, Muraoka A, Hato S, Kimura T, Tanakaya K, Kikuchi S, Tanabe S, Noma K, Nishizaki M, Kagawa S, Shirakawa Y, Kamikawa Y, Fujiwara T. Multicenter retrospective study to evaluate the efficacy and safety of the double-flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD-FLAP Study).Ann Gastroenterol Surg. 2019;3:96-103.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 48][Cited by in RCA: 69][Article Influence: 11.5][Reference Citation Analysis (1)]
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ. 2021;372:n71.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 44932][Cited by in RCA: 40535][Article Influence: 10133.8][Reference Citation Analysis (2)]
Matsuo K, Shibasaki S, Suzuki K, Serizawa A, Akimoto S, Nakauchi M, Tanaka T, Inaba K, Uyama I, Suda K. Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis.Surg Endosc. 2023;37:3478-3491.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 8][Cited by in RCA: 7][Article Influence: 3.5][Reference Citation Analysis (0)]
Hu Q, Ohashi M, Ri M, Makuuchi R, Irino T, Hayami M, Sano T, Nunobe S. Safety of robotic double-flap technique following proximal gastrectomy in the introductory phase compared with laparoscopic procedure: a propensity score-matched analysis.Surg Endosc. 2024;38:5824-5831.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 4][Reference Citation Analysis (0)]
Tsumura T, Kuroda S, Nishizaki M, Kikuchi S, Kakiuchi Y, Takata N, Ito A, Watanabe M, Kuwada K, Kagawa S, Fujiwara T. Short-term and long-term comparisons of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy by the double-flap technique and laparoscopy-assisted total gastrectomy for proximal gastric cancer.PLoS One. 2020;15:e0242223.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 6][Cited by in RCA: 24][Article Influence: 4.8][Reference Citation Analysis (1)]
Cizmic A, Romic I, Balla A, Barabino N, Anania G, Baiocchi GL, Bakula B, Balagué C, Berlth F, Bintintan V, Bracale U, Egberts JH, Fuchs HF, Gisbertz SS, Gockel I, Grimminger P, van Hillegersberg R, Inaki N, Immanuel A, Korr D, Lingohr P, Mascagni P, Melling N, Milone M, Mintz Y, Morales-Conde S, Moulla Y, Müller-Stich BP, Nakajima K, Nilsson M, Reeh M, Sileri P, Targarona EM, Ushimaru Y, Kim YW, Markar S, Nickel F, Mitra AT. An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.Surg Endosc. 2024;38:488-498.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 3][Reference Citation Analysis (0)]
Tian Z, Cheng Y, Wang Y, Ren J, Wang S, Wang D. A 3-Arm case-matched analysis of anti-reflux reconstruction methods after laparoscopic proximal gastrectomy - Single tract jejunal interposition vs double tract reconstruction vs tube-like stomach reconstruction.Eur J Surg Oncol. 2025;51:109482.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 2][Reference Citation Analysis (0)]
Nakamura M, Nakamori M, Ojima T, Katsuda M, Iida T, Hayata K, Matsumura S, Kato T, Kitadani J, Iwahashi M, Yamaue H. Reconstruction after proximal gastrectomy for early gastric cancer in the upper third of the stomach: an analysis of our 13-year experience.Surgery. 2014;156:57-63.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 67][Cited by in RCA: 84][Article Influence: 7.6][Reference Citation Analysis (1)]
Yasuda A, Yasuda T, Imamoto H, Kato H, Nishiki K, Iwama M, Makino T, Shiraishi O, Shinkai M, Imano M, Furukawa H, Okuno K, Shiozaki H. A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy.Gastric Cancer. 2015;18:850-858.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 27][Cited by in RCA: 36][Article Influence: 3.6][Reference Citation Analysis (1)]
Yang HK, Hyung WJ, Han SU, Lee YJ, Park JM, Cho GS, Kwon OK, Kong SH, Kim HI, Lee HJ, Kim W, Ryu SW, Jin SH, Oh SJ, Ryu KW, Kim MC, Ahn HS, Park YK, Kim YH, Hwang SH, Kim JW, Kim JJ. Comparison of surgical outcomes among different methods of esophagojejunostomy in laparoscopic total gastrectomy for clinical stage I proximal gastric cancer: results of a single-arm multicenter phase II clinical trial in Korea, KLASS 03.Surg Endosc. 2021;35:1156-1163.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 9][Cited by in RCA: 22][Article Influence: 4.4][Reference Citation Analysis (0)]
Zheng J, Wang X, Yu J, Hu Q, Zhan Z, Zhou S, Xu J, Li Q, Song C, Wang C, Zhao Q, Xu H, Shi H, Guo Z; Investigation on Nutrition Status and Clinical Outcome of Common Cancers (INSCOC) Group. Global Leadership Initiative on Malnutrition criteria: Clinical benefits for patients with gastric cancer.Nutr Clin Pract. 2025;40:239-251.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 1][Reference Citation Analysis (0)]
Brown D, Loeliger J, Stewart J, Graham KL, Goradia S, Gerges C, Lyons S, Connor M, Stewart S, Di Giovanni A, D'Angelo S, Kiss N. Relationship between global leadership initiative on malnutrition (GLIM) defined malnutrition and survival, length of stay and post-operative complications in people with cancer: A systematic review.Clin Nutr. 2023;42:255-268.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 26][Cited by in RCA: 27][Article Influence: 13.5][Reference Citation Analysis (0)]
