Comparison on the reflux and nutritional status of different reconstruction methods after laparoscopic proximal gastrectomy: a systematic review and network meta-analysis.

[BACKGROUND] The rising prevalence of gastric cancer in the upper third of the stomach has generated considerable interest in laparoscopic proximal gastrectomy (LPG). Traditional esophagogastric anastomosis after LPG has been associated with postoperative reflux issues. Despite the availability of various improved reconstruction techniques, there is still ongoing debate on the optimal approach. This network meta-analysis seeks to assess the reflux and nutritional outcomes associated with various reconstruction techniques subsequent to LPG.

[METHODS] A comprehensive literature search was performed across five databases: PubMed, Medline, Embase, Cochrane Library, and Web of Science. The reconstruction methods following LPG include esophagogastrostomy (EG), jejunal interposition (JI), jejunal pouch interposition (JPI), double-flap technique (DFT), double-tract reconstruction (DTR), gastric tube reconstruction (GT), and side overlap with fundoplication by Yamashita (SOFY). Network meta-analyses were performed to consolidate outcome measures, such as reflux esophagitis (RE), postoperative reflux symptoms, and nutritional status.

[RESULTS] This meta-analysis encompasses 16 studies published from 2009 to 2023, involving a total of 1,184 participants and examining 7 distinct reconstruction methods. The results indicated that patients who received DFT [odds ratio (OR) 13.27; 95% confidence interval (CI) 2.86-61.45] had a significantly lower rate of RE compared to those who underwent EG, as did patients who underwent SOFY (OR 4.58, 95% CI 1.16-18.10). Moreover, the DFT group demonstrated superior anti-reflux efficacy compared to the JI and DTR groups. Regarding nutritional status, both the JI group [standard mean difference (SMD) 12.16; 95% CI 3.57-20.76] and the DFT group (SMD 9.16; 95% CI 2.21-16.11) exhibited higher albumin levels compared to the EG interventions.

[CONCLUSION] DFT has shown promising efficacy in anti-reflux and postoperative nutritional status. Furthermore, SOFY demonstrates efficacy in the management of reflux, whereas JI is linked to improved postoperative nutritional outcomes following LPG. While providing valuable insights, it is important to note that the comparative analyses of JPI and SOFY rely on single-trial data with modest sample sizes, which may affect the precision of comparative effect estimates.

[REGISTRATION] This network meta-analysis was registered on the PROSPERO (CRD42023414346).