# Modified Proximal Gastrectomy and D2 Lymphadenectomy Is an Oncologically Sound Operation for Locally Advanced Proximal and GEJ Adenocarcinoma

## TL;DR

A modified stomach-sparing surgery for upper stomach cancer shows similar survival and better quality of life compared to full stomach removal.

## Contribution

A modified proximal gastrectomy with D2 lymphadenectomy is proposed for locally advanced upper stomach cancers, preserving more stomach tissue while maintaining oncologic safety.

## Key findings

- Modified proximal gastrectomy achieved R0 resection in all 14 patients with no locoregional recurrences.
- Patients showed better weight maintenance and hemoglobin levels compared to traditional total gastrectomy.
- The procedure preserved key lymph node stations while removing others for oncologic adequacy.

## Abstract

Gastric cancer patterns have changed in the US and Western Europe, with more cases now occurring in the upper stomach. While surgery remains the main treatment, removing the entire stomach (total gastrectomy) can lead to long-term issues like weight loss and nutritional problems. This study looked at an alternative, more stomach-sparing surgery called proximal gastrectomy (PG) with double tract reconstruction (DTR) for patients with upper stomach cancers. Fourteen patients at the Mayo Clinic had this surgery and were compared to others who had more extensive stomach removals. PG patients had similar survival rates, recovery, and complication rates, but showed signs of better weight maintenance and higher blood levels (hemoglobin), possibly due to preserved stomach function and improved nutrient absorption. The findings suggest PG with DTR may be a safe and effective option for certain patients with tumors limited to the upper stomach and with specific criteria (like tumor size and location). This approach may improve quality of life after surgery, but larger studies are needed to confirm these early results and refine patient selection.

Background: Proximal gastrectomy (PG) with double tract reconstruction (DTR) offers organ preservation for early gastric cancers, leading to reduced vitamin B12 deficiency, less weight loss, and improved quality of life. The JCOG1401 study confirmed excellent long-term outcomes for PG in stage I gastric cancer. However, in locally advanced proximal gastric cancer (LAPGC), preserving the gastric body and lymph node station 4d may compromise margin clearance and adequate lymphadenectomy. Methods: We propose a modified PG that removes the distal esophagus, gastroesophageal junction (GEJ), cardia, fundus, and gastric body, preserving only the antrum and performing DTR. Lymphadenectomy is also adapted, removing stations 1, 2, 3a, 4sa, 4sb, 4d, 7, 8, 9, 10 (spleen preserving), 11, and lower mediastinal nodes (stations 19, 20, and 110), while preserving stations 3b, 5, and 6. Indications for this procedure include GEJ (Siewert type II and III) and proximal gastric cancers with ≤2 cm distal esophageal involvement and ≤5 cm gastric involvement. Results: In our initial experience with 14 patients, we achieved R0 resection in all patients, adequate lymph node harvest (median 24 nodes, IQR 18–38), and no locoregional recurrences at a median follow-up of 18 months. We also found favorable postoperative weight loss, reflux, and anemia in the PG cohort. Conclusion: While larger studies and long-term data are still needed, our early results suggest that modified PG—despite sparing only the antrum—retains the key benefits of PG over total gastrectomy, including better weight maintenance and improved hemoglobin levels, while maintaining oncologic outcomes for LAPGC.