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Billroth-I anastomosis in distal subtotal gastrectomy for non-early gastric adenocarcinoma

Sevak S Shahbazyan
Sevak S Shahbazyan
, 
Mushegh A Sahakyan
Mushegh A Sahakyan
, 
Artak Gabrielyan
Artak Gabrielyan
, 
Xiaoran Lai
Xiaoran Lai
, 
Aram Martirosyan
Aram Martirosyan
, 
Hmayak Petrosyan
Hmayak Petrosyan
, 
Shushan Yesayan
Shushan Yesayan
 und 
Artur M Sahakyan
Artur M Sahakyan
   | 04. Sept. 2023
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Article Category: Research Article
Online veröffentlicht: 04. Sept. 2023
Seitenbereich: 356 - 363
Eingereicht: 20. Apr. 2023
Akzeptiert: 27. Juli 2023
DOI: https://doi.org/10.2478/raon-2023-0041
Schlüsselwörter
© 2023 Sevak S Shahbazyan et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

FIGURE 1.

Survival in patients with non-early non-metastatic gastric cancer undergoing subtotal distal gastrectomy with Billroth I and Billroth II reconstruction – propensity-matched analysis (1:1).
Survival in patients with non-early non-metastatic gastric cancer undergoing subtotal distal gastrectomy with Billroth I and Billroth II reconstruction – propensity-matched analysis (1:1).

Pathology findings in patients with non-early gastric adenocarcinoma undergoing distal subtotal gastrectomy

Variable Unmatched Propensity score matched
B-I (n = 165) B-II (n = 167) p-value B-I (n = 97) B-II (n = 97) p-value
Tumor size, cm, mean (SD) 4.5 (1.7) 6.2 (2.4) 0.001 5.1 (1.5) 5.2 (1.5) 0.52
pT stage, n (%) 0.046 0.28
  T1–T2 69 (41.8%) 49 (29.3%) 32 (33%) 31 (32%)
  T3 70 (42.4%) 85 (50.9%) 44 (45.4%) 53 (54.6%)
  T4a/T4b 26 (15.8%) 33 (19.8%) 21 (21.6%) 13 (13.4%)
pN stage, n (%) 0.089 0.62
  N0 47 (28.5%) 55 (32.9%) 27 (27.8%) 32 (33%)
  N1 31 (18.8%) 17 (10.2%) 14 (14.4%) 10 (10.3%)
  N2 38 (23%) 34 (20.4%) 25 (25.8%) 23 (23.7%)
  N3a 32 (19.4%) 47 (28.1%) 19 (19.6%) 24 (24.7%)
  N3b 17 (10.3%) 14 (8.4%) 12 (12.4%) 8 (8.2%)
Disease stage (AJCC), n (%) 0.1 0.95
  I B 29 (17.6%) 26 (15.6%) 13 (13.4%) 15 (15.5%)
  II A 32 (19.4%) 26 (15.6%) 17 (17.5%) 18 (18.6%)
  II B 29 (17.6%) 16 (9.6%) 16 (16.5%) 14 (14.4%)
  III A 33 (20%) 36 (21.6%) 24 (24.7%) 21 (21.6%)
  III B 25 (15.2%) 41 (24.6%) 15 (15.5%) 20 (20.6%)
  III C 17 (10.3%) 22 (13.2%) 12 (12.4%) 9 (9.3%)
Detected lymph nodes, mean (SD) 27 (12) 18 (9) 0.001 27 (12) 19 (10) 0.001
Positive lymph nodes, mean (SD) 6 (7) 6 (7) 0.98 6.4 (8.1) 5.6 (7.2) 0.44
Lymph node ratio, mean (SD) 0.21 (0.25) 0.28 (0.27) 0.52 0.24 (0.27) 0.28 (0.27) 0.27
R0 resection, n (%) 151 (91.5%) 120 (71.9%) 0.001 87 (89.7%) 80 (82.5%) 0.16
Tumor differentiation, n (%) 0.018 0.51
  Well 30 (18.2%) 22 (13.2%) 15 (15.5%) 15 (15.5%)
  Middle 44 (26.7%) 60 (35.9%) 26 (26.8%) 33 (34%)
  Poor/non-differentiated 91 (55.1%) 85 (50.9%) 56 (57.7%) 49 (50.5%)

Long-term oncologic outcomes after distal subtotal gastrectomy with Billroth I vs Billroth II reconstruction for non-early gastric adenocarcinoma*

Variable Unmatched Propensity score matched
B-I (n = 164) B-II (n = 165) p-value B-I (n = 96) B-II (n = 95) p-value
Adjuvant chemotherapy, n (%) 52 (31.7%) 44 (26.7%) 0.32 36 (37.5%) 26 (27.4%) 0.18
Recurrence, n (%) 34 (20.7%) 60 (36.4%) 0.002 21 (21.9%) 34 (35.8%) 0.054
Recurrence type, n (%)
Local 4 (2.4%) 16 (9.7%) 0.006 3 (3.1%) 11 (11.6%) 0.022
Distant metastases 12 (7.3%) 25 (15.2%) 0.025 8 (8.3%) 12 (12.6%) 0.3
Peritoneal carcinomatosis 18 (11%) 19 (11.5%) 0.88 10 (10.4%) 11 (11.6%) 0.65
Overall survival, months, median 45 (35.4–54.6) 29 (24.3–33.7) 0.036 45 (30.9–59.1) 29 (24.9–33.1) 0.22
  3-year 59% 41.1% 57% 38.4%
  5-year 34.6% 28.7% 32.9% 28.4%

Uni- and multivariable analysis of prognostic factors for tumor recurrence following distal subtotal gastrectomy for non-early gastric adenocarcinoma (Propensity score matching [PSM] cohort)

Variable Univariable Multivariable
Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value
Age, years 0.99 (0.96–1.01) 0.33
Gender (female) 1.34 (0.71–2.51) 0.37
BMI, kg/m2 0.99 (0.93–1.07) 0.89
Comorbidity 0.74 (0.38–1.46) 0.39
ASA score (III–IV) 0.86 (0.31–2.4) 0.78
CEA, ng/mL 1.0 (0.99–1.02) 0.59
Ca 19-9, U/mL 1.0 (0.99–1.001) 0.93
Extended gastrectomy 0.99 (0.19–5.26) 0.99
B-II reconstruction (vs. B-I) 1.99 (1.05–3.78) 0.035 ———————————— —
Operative time 1.012 (1.001–1.024) 0.038 ———————————— —
Estimated blood loss 1.001 (0.99–1.01) 0.65
Red blood cell transfusion 0.26 (0.06–1.18) 0.082
Severe complications 2.06 (0.53–7.96) 0.29
Relaparotomy 2.59 (0.62–10.74) 0.19
Tumor size 1.13 (0.92–1.38) 0.25
pT stage
  T1–T2 reference reference
  T3 3.86 (1.76–8.48) 0.001 3.13 (1.36–7.19) 0.007
  T4a/T4b 1.04 (0.32–3.35) 0.95 0.64 (0.14–2.86) 0.56
pN stage
  N0 Reference ———————————— —
  N1 1.82 (0.57–5.82) 0.32 ———————————— —
  N2 2.31 (0.89–5.95) 0.08 ———————————— —
  N3a 4.31 (1.69–10.94) 0.002 ———————————— —
  N3b 3.18 (0.98–10.26) 0.05 ———————————— —
Detected lymph nodes 0.96 (0.94–0.99) 0.022 0.96 (0.93–1.01) 0.06
Lymph node ratio 1.05 (1.01–1.09) 0.025 1.01 (1.0–1.03) 0.043
R0 resection 3.2 (1.36–7.55) 0.008 2.41 (0.85–6.84) 0.1
Tumor differentiation
  Well reference
  Middle 1.18 (0.59–2.37) 0.65
  Poor 0.63 (0.25–1.59) 0.33
Adjuvant chemotherapy 1.28 (0.66–2.47) 0.46

Perioperative data in patients with non-early gastric adenocarcinoma undergoing distal subtotal gastrectomy

Variable Unmatched Propensity score matched
B-I (n = 165) B-II (n = 167) p-value B-I (n = 97) B-II (n = 97) p-value
Age, years, mean (SD) 60.8 (11.7) 62.6 (10.9) 0.16 60.9 (10.9) 63.2 (11.6) 0.46
Gender (female), n (%) 74 (44.8%) 59 (35.3%) 0.08 42 (43.3%) 43 (44.3%) 0.26
BMI, kg/m2, mean (SD) 26.0 (6.5) 25.5 (5.1) 0.55 26.3 (5.9) 25.4 (5.5) 0.31
Comorbidity, n (%) 129 (78.2%) 109 (65.3%) 0.01 76 (78.3%) 63 (64.9%) 0.04
Cardiovascular disease, n (%) 88 (53.3%) 75 (44.9%) 0.13 50 (51.5%) 46 (47.4%) 0.58
Diabetes mellitus, n (%) 18 (10.9%) 16 (9.6%) 0.69 14 (14.4%) 7 (7.2%) 0.13
Number of comorbidities, mean (SD) 2.3 (1.1) 3.1 (0.9) 0.001 2.3 (1.1) 3.0 (0.8) 0.001
ASA score (III–IV), n (%) 145 (87.9%) 145 (86.8%) 0.77 87 (89.7%) 88 (90.7%) 0.81
Hemoglobin, g/dL, mean (SD) 124 (27) 119 (29) 0.09 122 (28) 119 (29) 0.42
Total protein, g/dL, mean (SD) 72 (8.4) 72 (5.9) 0.53 70.5 (9.8) 72.1 (5.8) 0.15
CEA, ng/mL, median (range) [IQR]* 1 (0.5–627.2) [1–2] 1.5 (0.5–188) [1–3] 0.02 1 (0.5–174) [1–2] 1 (0.5–100) [1–2] 0.81
Ca 19-9, U/mL, median (range) [IQR]* 8 (1–1549) [3–21] 9 (1–999) [3–29] 0.62 8.3 (1–1549) [4–25] 9 (1–999) [3–30] 0.7
Location in antrum, n (%) 160 (97%) 133 (79.6%) 0.001 93 (95.9%) 94 (96.9%) 0.65
Extended gastrectomy, n (%) 3 (1.8%) 25 (15%) 0.001 3 (3.1%) 4 (4.1%) 0.65
Operative time, min, mean (SD) 144 (28) 168 (29) 0.001 143 (27) 165 (28) 0.001
Red blood cell transfusion, n (%) 17 (10.3%) 13 (7.8%) 0.42 12 (12.4%) 7 (7.2%) 0.23
Severe complications, n (%) 8 (4.8%) 13 (7.8%) 0.27 5 (5.2%) 7 (7.2%) 0.53
Anastomotic leakage, n (%) 4 (2.4%) 5 (3%) 1.0 1 (1%) 2 (2.1%) 0.56
Relaparotomy, n (%) 7 (4.2%) 11 (6.6%) 0.35 4 (4.1%) 5 (5.2%) 0.71
30-day mortality, n (%) 1 (0.6%) 2 (1.2%) 1.0 1 (1%) 2 (2.1%) 0.56
90-day mortality, n (%) 1 (0.6%) 4 (2.4%) 0.37 1 (1%) 4 (4.1%) 0.36
Postoperative days, median (range) 11 (6–48) [9–13] 11 (5–72) [9–13] 0.51 10 (6–48) [9–13] 11 (5–72) [9–14] 0.47
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