Comparing safety and short-term outcomes of proximal gastrectomy with double-flap technique and other reconstructions for proximal gastric cancer: a systematic review and meta-analysis.

[BACKGROUND] Proximal gastrectomy (PG) for proximal gastric cancer (PGC) is associated with complications such as gastroesophageal reflux. The double-flap technique (DFT) has been proposed as an effective anti-reflux reconstruction method. This systematic review aims to compare the safety and short-term outcomes of DFT versus other reconstruction methods for proximal gastrectomy.

[METHODS] The present meta-analysis was conducted, following PRISMA guidelines. Studies comparing DFT with other reconstruction methods for proximal gastric cancer were included. Outcomes assessed included surgical parameters (operative time and intraoperative blood loss), postoperative reflux incidence (subjective reflux symptoms, objective evaluation using endoscopy and proton pump inhibitor (PPI) intake), and other short-term postoperative indicators (postoperative complications and length of postoperative hospital stay). Data were extracted from PubMed, Web of Science, EMBASE, and the Cochrane Library through June 1st, 2025. Risk of bias was assessed using the Newcastle-Ottawa Scale. We performed meta-analyses using Review Manager 5.4, presenting mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI).

[RESULTS] A total of 11 retrospective studies were included in this meta-analysis. Qualitative analysis showed DFT had anastomotic leakage, stricture, and pancreatic fistula rates of 1.4%, 5.9%, and 1.8%, respectively. Postoperatively, 17.4% of patients took PPIs, and 3.4% reported subjective reflux symptoms. One year after surgery, during follow-up endoscopy, 5.1% of patients were found to have gastroesophageal reflux (Los Angeles classification grade B or higher). Meta-analysis results showed that the DFT group had significantly longer operative times but reduced intraoperative blood loss compared to the esophagojejunostomy (EJ) groups. Postoperative complication rates, including anastomotic leakage and stricture, were similar across the double tract reconstruction (DTR) group and other esophagogastrostomy (EG) groups. While no significant differences were found in reflux symptoms or esophagitis at the 1-year follow-up, DFT was associated with significantly reduced PPI usage, especially compared to the EG group.

[CONCLUSIONS] DFT is a safe and effective method for reconstructing the digestive tract following PG, offering a balance between surgical complexity and favorable short-term outcomes. Although it does not fully eliminate reflux, its reduced PPI dependency and acceptable complication profile make it a promising option. Further large-scale randomized trials are needed to confirm these findings.

[TRIAL REGISTRATION] The protocol was prospectively registered on the PROSPERO website as CRD42025636187 on January 9th, 2025.