Enhancing Quality of Life of Proximal Gastrectomy: A Comprehensive Review of Anastomotic Innovations and Challenges

BACKGROUND: In recent years, the incidence of early upper gastric cancer has increased, leading to a wider adoption of proximal gastrectomy (PG) as a possible treatment option. PG is preferred over total gastrectomy (TG) due to its superior postoperative nutritional status and improved surgical safety. However, PG is associated with a considerable risk of anastomosis-related complications, such as gastroesophageal reflux and anastomotic stenosis, which limit its widespread application. METHODS: We conducted a narrative review of comparative studies, prospective studies and retrospective study, that described reconstructive techniques after PG. End-points of interest were incidence of reflux esophagitis, anastomotic stenosis, time of follow-up, nutritional parameters. RESULTS: Esophago-gastrostomy, the simplest reconstruction method, was associated with highest reflux rates of 18%-55% and stenosis rates of 1.1%-27.8%. Anti-reflux modifications such as side-overlap, double-flap technique (DFT) and gastric tube lowered reflux rate distinctly, especially DFT, lowered reflux rates to 2%-16.7%. But DFT carried a 4%-26.3% stenosis risk and longer operative time. Jejunal interposition (JI) gave 2.1%-100% reflux rates and 0%-31.8% stenosis, yet required three anastomoses and limited endoscopic surveillance. Double-tract reconstruction (DTR) achieved the promising anti-reflux outcome, with preserved duodenal passage. However, it may increase surgery costs and prolong surgical time. CONCLUSION: Our findings provide a solid foundation for reconstruction methods selection that enhance postoperative quality of life and highlight future directions for improving PG outcomes. DTR and DFT, currently offer the best balance between reflux control and anastomotic stenosis after PG. Prospective clinical research and innovation are expected to further improve these techniques and may discover an optimal universal approach to address long-term challenges.