Double-tract Reconstruction Research Articles

Multicenter prospective randomized controlled trial of comparing laparoscopic proximal gastrectomy and laparoscopic total gastrectomy for upper third early gastric cancer (KLASS-05).

TPS184 Background: Proximal gastrectomy (PG) is rarely performed for upper third early gastric cancer (EGC) because of postoperative reflux esophagitis. Recently, PG with double tract reconstruction was introduced and reported to have a reflux of approximately the same frequency as total gastrectomy (TG) with esophagojejunostomy. PG has several theoretical advantages over TG but has not yet been proven in randomized controlled trial. This study aimed to provide scientific evidence of laparoscopic PG with double tract reconstruction as a standard procedure for proximal EGC. Methods: The present trial is multicenter, prospective, randomized, controlled trial with superiority design. A total of 138 patients with upper third cT1N0M0 gastric adenocarcinoma are randomized to laparoscopic PG with double tract reconstruction and laparoscopic TG with esophagojejunostomy. Patients are enrolled for two years and followed up for two years. Primary co-endpoints are hemoglobin change and vitamin B12 cumulative supplement quantity after 2 years of operation. We used the alpha-split method to set the hemoglobin to 4% and vitamin B12 to 1% for alpha. The sample size needed was 62 patients for each arm. Accounting for 10% follow-up loss, the enrollment of 69 patients in each group was required. Secondary endpoints are prevalence rate of postoperative reflux esophagitis, morbidity and mortality, quality of life 2-year after operations, relapse-free survival, and overall survival. Nineteen investigators from 10 institutes participated in this trial. The first patient was enrolled on October 27, 2016 and we completed the patient enrollment on September 17, 2018. Clinical trial information: NCT02892643.

Aortoenteric fistula following overlap esophagojejunal anastomosis using linear staplers for cancer of the esophagogastric junction: a case report

BackgroundAortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy.Case presentationA 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site.ConclusionsTo our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

Combined Aggressive Distal Gastrectomy and Double-Tract Reconstruction for Palliation of Incurable Locally Invasive Distal Gastric Cancer With Gastric Outlet Obstruction

Objective:To evaluate combined aggressive distal gastrectomy (ADG) and double-tract (DT) reconstruction (ADGDTR) for palliative treatment of gastric cancer with gastric outlet obstruction (GOO).Summary of Background Data:An effective standard palliation procedure has not been identified for patients with incurable gastric cancer.Methods:I retrospectively evaluated patients presenting to my clinic with GOO secondary to locally invasive distal gastric cancer between March 1996 and March 2011. Following a complete workup, patients underwent ADGDTR. ADG included the gastric tumor in whole or in part. DT reconstruction consisted of gastrojejunostomy, jejunoduodenostomy, and jejunojejunostomy.Results:In the enrolled patients (n = 7; 5 male; mean age, 71 years [range, 60–83 years]), preoperative comorbidities included anemia (7), diabetes mellitus (2), hepatic cirrhosis (1), cardiac ischemia (1), and Parkinson disease (1). The lesion invaded the pancreas in all patients, and the transverse mesocolon, liver, and mesentery were each involved in 1 patient. Metastatic disease affected the lymph nodes in 5 patients, liver in 1, and peritoneal cavity in 4. Peritoneal lavage cytology was positive in 3 patients and untested in 4. The mean operation time was 207 minutes (range, 150–295 minutes), and mean blood loss was 290 g (range, 110–480 g). Six patients had no postoperative complications, but 1 died of abdominal sepsis. The mean length of hospitalization was 43 days (range, 28–73 days), and mean survival was 8.3 months (range, 2–22 months). Six patients tolerated a low-residue or regular diet postoperatively.Conclusions:ADGDTR provided effective, low-risk palliation and long-term oral ingestion in patients with incurable, locally invasive distal gastric cancer with GOO.

Similar hematologic and nutritional outcomes after proximal gastrectomy with double-tract reconstruction in comparison to total gastrectomy for early upper gastric cancer.

Proximal gastrectomy offers theoretical benefits over total gastrectomy in terms of hematologic and nutritional outcomes. However, little evidence confirming these benefits has been reported. The aim of this study was to assess the hematologic and nutritional outcomes of proximal gastrectomy with double-tract reconstruction in comparison to those of total gastrectomy. We retrospectively analyzed data from 80 patients with stage I gastric cancer who underwent proximal gastrectomy with double-tract reconstruction (n = 38) or total gastrectomy (n = 42) from September 2014 to December 2015. We compared hematologic (including hemoglobin, ferritin, vitamin B12, etc.) and nutritional outcomes [including body mass index (BMI), serum total protein, albumin, total cholesterol, and total lymphocyte count] between the two groups. We found no significant differences in changes in hemoglobin (P = 0.250) or cumulative incidence of iron deficiency anemia (P = 0.971) during a median follow-up period of 24months (range 18-30 months) after surgery. Cumulative incidence of vitamin B12 deficiency also did not differ significantly between the proximal and total gastrectomy groups (P = 0.087). BMI changes from baseline were not significantly different between the two groups (P = 0.591). Likewise, there were no statistically significant differences in nutritional outcomes. Proximal gastrectomy with double-tract reconstruction exhibited similar outcomes in terms of hematologic and nutritional features in comparison to total gastrectomy.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients

BackgroundThis study aimed to evaluate the surgical outcomes of laparoscopic proximal gastrectomy (LPG) reconstructed by the double-tract method in comparison to those of laparoscopic total gastrectomy (LTG). MethodsA retrospective review of the prospectively established database identified early gastric cancer patients who underwent LPG (n = 34) or LTG (n = 46) between January 2011 and December 2015. Baseline characteristics and surgical outcomes including postoperative complications, changes in body composition, nutritional status, and quality of life (QOL) after surgery were compared between the LPG and LTG patients. ResultsOperating time was significantly longer in the LTG group (240.7 ± 43.9 vs. 211.7 ± 32.8 min, p = 0.007). The incidence of grade II or more complications and the hospital stay were comparable between the groups. There was no significant difference between the groups in terms of body composition using a bioelectrical impedance method in 1 year postoperatively. Nutritional status assessed by serum hemoglobin, iron, vitamin B12, albumin, total protein, and total cholesterol levels and postoperative changes in quality of life up to 2 years after surgery were also similar between the groups. Vitamin B12 supplementation was required in 75.4% of the patients in the LTG group and 46.5% in the LPG group within 2 years after surgery (p = 0.005). ConclusionLPG with double-tract reconstruction appears superior in preventing vitamin B12 deficiency compared to LTG, particularly after 1 year after the surgery, although it offered little benefit in terms of postoperative body composition changes and QOL.

Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type II and III adenocarcinoma of the esophagogastric junction: a prospective randomized controlled study

Objective To investigate the clinical efficacy of jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG). Methods The prospective study was conducted. The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected. All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table, including patients using single-tract jejunal interposition reconstruction in the single-tract group and patients using double-tract jejunal interposition reconstruction in the double-tract group. Digestive tract reconstruction: after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum, single-tract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma, and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the single-tract group. Patients in the double-tract group used the same digestive tract reconstruction, but jejunum was not ligated. The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy. Observation indicators: (1) intra- and post-operative situations; (2) follow-up situations. Follow-up using telephone interview was performed to detect postoperative complication, gastrointestinal function and body mass index (BMI) up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the nonparametric test. Repeated measurement data were analyzed by the repeated measures ANOVA. Comparisons of count data were done using chi-square test. Ordinal data were analyzed by the Kruskal Wallis H test. Results One hundred and eight patients were screened for eligibility, including 55 in the single-tract group and 53 in the double-tract group. (1) Intra- and post-operative situations: total operation time, digestive tract reconstruction time, volume of intraoperative blood loss, time to initial anal exsufflation, postoperative complications, cases with gastroesophageal reflux, intestinal obstruction and Visick grading > Ⅱ and duration of postoperative hospital stay were respectively (145±26)minutes, (30±6)minutes, (181±37)mL, (53±16)hours, 1, 1, 1, (10.0±2.4)days in the single-tract group and (139±29)minutes, (26±3)minutes, (176±31)mL, (50±17)hours, 3, 0, 3, (9.4±1.4)days in the double-tract group, with no statistically significant difference between groups (t=0.725, 0.219, 0.162, -0.576, χ2=2.960, 5.830, t=-0.993, P>0.05). Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks, and were improved by symptomatic treatment such as increasing the solid food intake. One patient in the single-tract group had internal hernia-induced intestinal obstruction and was cured by reoperation. There was no anastomotic leakage, bleeding, infection, dumping syndrome and gallstone between groups. Of 108 patients, 71 underwent 6-cycle SOX chemotherapy, including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall. (2) Follow-up situations: 108 patients were followed up for 12.0-48.0 months, with a median time of 28.6 months. During the follow-up, bowel sound in the double-tract group and single-tract group was 8 times / minute (range, 5-12 times / minute) and 3 times / minute (range, 2-5 times / minute), with a statistically significant difference between groups (Z=-0.692, P 0.05). There was a statistically significant difference in changing trend of BMI between groups (F=24.930, P<0.05). Conclusion Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don′t affect secretion function of gastric remnant, but there are frequent bowel sounds and obvious weight loss. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Proximal gastrectomy; Siewert type Ⅱ; Siewert type Ⅲ; Digestive tract reconstruction; Single-tract; Double-tract

Laparoscopic Proximal Gastrectomy Maintains Body Weight and Skeletal Muscle Better Than Total Gastrectomy.

Laparoscopic proximal gastrectomy (LPG) is performed as a function-preserving surgery for patients with early proximal gastric malignant tumors; however, whether LPG has advantages postoperatively compared with laparoscopic total gastrectomy (LTG) is debatable, especially with regard to nutritional outcomes. We evaluated 20 patients who underwent LTG and 10 patients who underwent LPG with double tract reconstruction (LPG-DT) who were diagnosed preoperatively with T1a or T1b N0 Stage IA gastric cancer in our department in the same time period. The statistical relevance of complications, surgical maneuvers, clinical factors and changes in weight, skeletal muscle index (SMI) and serum albumin levels after surgery was compared between the LPG-DT group and the LTG group. No differences between groups were observed in patient demographics, operation time, blood loss, complications, number of dissected lymph nodes and pathological stage. The body weight reduction rate was significantly lower in the LPG-DT group compared with the LTG group at 6 months (5.7 vs. 14.9%, respectively; p=0.0045) and 1 year after surgery (9.6 vs. 17.9%, respectively; p=0.0042). The SMI reduction rate of the LPG-DT group in the first postoperative year was significantly lower than that of the LTG group (9.3 vs. 18.3%, respectively; p=0.0057). Patients with early gastric cancer who underwent LPG-DT had acceptable morbidity and mortality, similar to those who underwent LTG. Body weight and SMI reduction rates were lower in the LPG-DT group than in the LTG group. Thus, LPG-DT is an appropriate procedure for patients with clinical Stage IA proximal gastric cancer.

Clinical research status of laparoscopic total gastrectomy in China

Many retrospective and cohort studies have shown that laparoscopic total gastrectomy(LTG) has advantages of less trauma, quicker recovery and better incision than open total gastrectomy, and is not inferior to laparotomy in safety and the short- and long-term outcomes, so it has been widely applied. However there is still a lack of high level evidence-based basis. At present, several prospective multicenter clinical studies are being carried out in China, Japan and South Korea which have high incidence of gastric cancer to demonstrate the safety and feasibility of LTG and evaluate its long-term outcomes as well. A multicenter randomized controlled clinical trial comparing the safety of laparoscopic and open radical gastrectomy(CLASS-02 Research) conducted by Professor Sun Yihong, Zhongshan Hospital of Fudan University, is under way. The subjects of this study were the patients with clinical stage I(, the lesion locating in the gastric body, gastric fundus, or the esophagogastric junction (not involving the cardia dentate line), who were expected to be treated with total gastrectomy. The primary outcome measures were early operative morbidity and mortality and the secondary outcome measures were early postoperative recovery course and postoperative hospital stay. It is believed that results of the study will provide a high level evidence-based basis for the safety of LTG. The ongoing JCOG-1401 study in Japan aims to assess the feasibility and safety of LTG and LAPG for the treatment of early gastric cancer. LTG (Roux-en-Y reconstruction) or LAPG (double-tract or jejunal interposition reconstruction) will be performed in patients with clinical stage I( gastric cancer in this study. The primary endpoint of the study is the incidence of anastomotic leakage, and the secondary endpoints are proportion of patients converted to open surgery, the time to the first flatus, analgesic requirement, postoperative body temperature, the overall survival and relapse-free survival. The follow-up time is at least 5 years, and the results will also effectively evaluate the long-term efficacy of LTG and LAPG in the treatment for early gastric cancer. No.10 lymph nodes dissection of D2 total gastrectomy is a major difficulty in LTG. Japanese JCOG-0110 study has showed that for proximal gastric cancer patients without involvement of the greater curvature of the stomach, routine splenectomy for No.10 lymph nodes dissection is not recommended. In this regard, Professor Huang Changming, Union Hospital of Fujian Medical University, led the ongoing CLASS-04 study to evaluate the safety, feasibility and clinical efficacy of laparoscopic No.10 lymph node dissection with spleen preservation for patients with locally advanced gastric cancer locating in the upper part of the stomach. The ongoing CLASS-02 and JCOG-1401 studies will answer whether LTG is suitable for the treatment of early gastric cancer. We believe that in the absence of high level evidence-based basis, LTG should be applied cautiously to advanced gastric cancer, and LTG for early gastric cancer patients should also be operated by experienced surgeons.

Double Tract vs. Roux-en-Y Reconstruction in the treatment of Gastric Cancer

Objective:Functional outcomes were prospectively compared between the standard Roux-en-Y and Double-tract reconstruction following a total gastrectomy and D2 lymphadenectomy.Methods:One hundred ten patients with gastric cancer were divided into two groups by the type of reconstruction. Age, gender, T stage, AJCC stage, length of operation, BMI (body mass index, kg/m2), time to soft diet, postoperative leakage of the esophagojejunostomy (EJS), stricture of the EJS, meal intake, and quality of life (QOL) were recorded.Results:The mean age in the R-Y group was 61.57, with the SD of 9.53, while in the DT group the mean age was 60.17 with a SD of 9.92. The BMI decline in the R-Y group was 4.09 with a SD of 1.11, while in the DT group it was 2.85 with a SD of 1.27. We found a highly significant statistical difference between the two groups in the rate of the BMI decline (p<0,001). We found no statistically significant difference regarding QOL between the two groups, p>0.05.Conclusions:The Double tract reconstruction is a simple procedure and the rate of the BMI decline is much smaller compared to the Roux-en-Y group.

Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series.

IntroductionWhen gastric cancer or carcinoid patients have coexisting diseases such as duodenal adenoma, FAP, or Crohn's disease, periodic observation of the duodenum is necessary.MethodsBetween August 2013 and April 2015, we performed four consecutive laparoscopic total gastrectomies with double tract reconstruction for duodenal surveillance. Three of the patients were diagnosed with gastric cancer, while the remaining patient was diagnosed with gastric carcinoid.ResultsNo deaths occurred, and three of the patients showed no early complications. One patient with Crohn's disease developed anastomotic leakage, but it was successfully managed conservatively. On endoscopy three to seven months later, we were able to observe the duodenum via jejunal anastomosis in all of the patients.DiscussionRoux-en-Y reconstruction is one of the options after laparoscopic total gastrectomy. However, given that periodical endoscopic examinations of the duodenum are strongly recommended after surgery, double-tract reconstruction may be preferable in these patients.ConclusionAlthough more detailed data are required, double-tract reconstruction may be the best choice for patients requiring total gastrectomy with regular check-up of the duodenum.

Laparoscopic proximal gastrectomy with oblique jejunogastrostomy

Proximal early gastric cancer is a good indication for totally laparoscopic proximal gastrectomy (TLPG) with double-tract reconstruction (DTR). However, when most of the dietary intake passes through the escape route of the jejunum, the functional benefits of proximal gastrectomy might be similar to those after total gastrectomy. Our DTR procedure was improved for easy passage through the remnant stomach. The purposes of this study were to present a novel technique for intracorporeal DTR using linear staplers after TLPG and to investigate surgical outcomes. DTR was performed using linear staplers only. A side-to-side jejunogastrostomy with twisting of both the remnant stomach and the anal jejunum was performed for the purpose of passing meals through the remnant stomach (an oblique jejunogastrostomy technique). The ten patients who underwent TLPG with DTR from January 2011 to August 2016 in Hokkaido University Hospital were retrospectively reviewed. Their clinicopathological characteristics and surgical and postoperative outcomes were collected and analyzed. The median duration of operation was 285 (range 146-440) min. No patients required blood transfusions. The number of dissected lymph nodes was 32 (range 22-56). There were no intraoperative complications, and no cases were converted to open surgery. All the patients were pT1N0M0 stage IA. No anastomotic leakage or complications were detected. Postoperative gastrography after reconstruction showed that contrast medium flowed mainly to the remnant stomach. The average percentage body weight loss was 14.0±7.1% at 10months. The average percentage decrease in serum hemoglobin was 5.4±10.4% at 12months. This novel technique for intracorporeal DTR provided a considerable advantage by the passage of dietary intake to the remnant stomach after LPG.

Esophagojejunostomy Using the Purse-String Suturing Device After Laparoscopic Total or Proximal Gastrectomy for Gastric Cancer.

Performing a safe esophagojejunostomy is important for the standardization of laparoscopic total gastrectomy. We have performed intracorporeal esophagojejunostomy by a circular stapler using the purse-string suturing device that we co-developed. The advantage of this device is that it makes use of the same surgical procedure as open surgery, but it does not depend on the surgeon's technical skills since this device does not require the laparoscopic hand-sewn technique. Furthermore, we have also adapted this device for double-tract reconstruction after laparoscopic proximal gastrectomy. In this study, we present the surgical procedures and postoperative short-term outcomes that were obtained using this novel technique. We enrolled 94 patients that underwent intracorporeal esophagojejunostomy by circular stapler using our device after laparoscopic total or proximal gastrectomy for gastric cancer between November 2009 and October 2016. Postoperative complications related to esophagojejunostomy were due to anastomotic stenosis in two cases (2.1%) and leakage of the jejunum stump in one case (1.1%). Intracorporeal esophagojejunostomy by circular stapler using the purse-string suturing device is safe and feasible. This method can be one of the standard procedures for performing intracorporeal esophagojejunostomy.

Laparoscopic proximal gastrectomy for upper third early gastric cancer

Laparoscopic proximal gastrectomy is theoretically superior to total gastrectomy in the treatment of upper third early gastric cancer, as the former is less invasive and better preserves function. Three major issues have limited the more widespread use of proximal gastrectomy: its oncologic safety, functional benefits, and risk of reflux esophagitis. Many recent studies suggest that the oncologic safety of laparoscopic proximal and total gastrectomy is similar, with proximal gastrectomy resulting in improved functional outcomes. To date, however, no standard reconstruction method has been developed to effectively prevent reflux esophagitis after proximal gastrectomy. Our recent retrospective study found that no patient who underwent laparoscopic proximal gastrectomy with double tract reconstruction experienced severe reflux esophagitis and that this method was superior to laparoscopic total gastrectomy in preventing anemia and vitamin B12 deficiency. This result led to the design of a randomized controlled trial, the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS) 05 (ClinicalTrials.gov; identifier: NCT02892643), which is currently comparing laparoscopic proximal gastrectomy with double tract reconstruction with laparoscopic total gastrectomy. This trial may help surgeons choose the optimal surgical approach and strategy for patients with proximal early gastric cancer.

Double-tract reconstruction after laparoscopic proximal gastrectomy using detachable ENDO-PSD.

Proximal gastrectomy (PG) is widely performed in Japan as a function-preserving surgical approach. Since esophagogastrostomy (EG) was associated with increased reflux symptoms and anastomotic strictures, we have chosen double-tract reconstruction (DTR) as the standard reconstruction method since March 2013. In this study, we described a novel method of laparoscopic DTR using detachable ENDO-PSD and compared its 1-year outcome with EG performed formerly in our institution. Patients who underwent laparoscopic PG between May 2005 and July 2014 were retrospectively divided into two groups based on the type of reconstruction and were subsequently analyzed (19 patients in the DTR group and 22 in the EG group). All of them underwent a laparoscopic PG with regional lymph node dissection. In the DTR group, the lower left port site was extended to 4cm, and an intracorporeal purse-string suture was performed using the detachable ENDO-PSD. The jejunogastrostomy was fashioned on the anterior side of the remnant stomach parallel to the transection line, 2cm from the cut end. The EG group used the conventional purse-string suture instrument through the 6cm upper midline mini-laparotomy incision. Patient characteristics, operative data, early operative complications and 1-year postoperative follow-up findings were compared between the two groups. The frequencies of reflux symptoms (10.5 vs. 54.5%, P=0.003), usage of proton pump inhibitors (31.6 vs. 72.7%, P=0.008), and anastomotic strictures (0 vs. 27%, P=0.014) were significantly lower in the DTR group as compared to the EG group. There were no significant differences between the two groups with regard to operation time, blood loss, postoperative hospital stay, postoperative complications, average postoperative/preoperative weight loss ratio, and postoperative/preoperative ratio of biochemical markers (hemoglobin, total protein, albumin, cholesterol). Our results indicate that DTR is a useful reconstruction method after PG, especially in terms of preventing reflux esophagitis and anastomotic strictures.

Laparoscopic proximal gastrectomy with double tract reconstruction

Laparoscopic proximal gastrectomy with double tract reconstruction

Laparoscopic Proximal Gastrectomy as a Surgical Treatment for Upper Third Early Gastric Cancer

Recently, the incidence of upper third gastric cancer has increased, and with it the number of endoscopic submucosal dissection (ESD) procedures performed has been increasing. However, if ESD is not indicated or non-curable, surgical treatment may be necessary. In the case of lower third gastric cancer, it is possible to preserve the upper part of the stomach; however, in the case of upper third gastric cancer, total gastrectomy is still the standard treatment option, regardless of the stage. This is due to the complications associated with upper third gastric cancer, such as gastroesophageal reflux after proximal gastrectomy rather than oncologic problems. Recently, the introduction of the double tract reconstruction method after proximal gastrectomy has become one of the surgical treatment methods for upper third early gastric cancer. However, since there has not been a prospective comparative study evaluating its efficacy, the ongoing multicenter prospective randomized controlled trial (KLASS-05) comparing laparoscopic proximal gastrectomy with double tract reconstruction and laparoscopic total gastrectomy is expected to be important for determining the future of treatment of upper third early gastric cancer.

Peer review report 2 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Peer review report 2 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Peer review report 1 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Peer review report 1 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Peer review report 3 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Peer review report 3 on “Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series”

Laparoscopic Proximal Gastrectomy with Double-Tract Reconstruction by Intracorporeal Anastomosis with Linear Staplers

Laparoscopic Proximal Gastrectomy with Double-Tract Reconstruction by Intracorporeal Anastomosis with Linear Staplers