TY - JOUR
AU - Yamaguchi, T
AB - Abstract Background Reflux oesophagitis is commonly encountered in the surgical treatment of cancer of the upper third of the stomach. The aim of this study was to describe a novel surgical technique and evaluate the clinical outcome of high segmental gastrectomy for early-stage proximal gastric cancer. Methods Thirty consecutive patients with early gastric cancer located in the upper third of the stomach were included, of whom 12 underwent high segmental gastrectomy and 18 underwent proximal gastrectomy with jejunal interposition. The incidence of reflux oesophagitis and nutritional parameters were compared between the two groups at 1 year after operation. Results One patient had mild reflux symptoms and two had endoscopic evidence of oesophagitis 1 year after high segmental gastrectomy. Half of the patients who had proximal gastrectomy had reflux symptoms of varying severity and 14 had endoscopic evidence of oesophageal changes at 1 year after surgery. There were significant differences between groups in the incidence of reflux symptoms (P = 0·016) and endoscopically detected gastro-oesophagitis (P < 0·001). There were no adverse events in either group, and the survival rate after high segmental gastrectomy appeared favourable. Conclusion Selected patients with early-stage proximal gastric cancer benefit from high segmental gastrectomy in terms of reduced reflex oesophagitis, without jeopardizing curability. Introduction The survival rate after gastrectomy for gastric cancer with complete removal of primary and secondary lymph nodes is more than 90 per cent in Japan1,2. Concern about quality of life following gastrectomy has increased in recent years. Previous studies have demonstrated that proximal gastrectomy can be performed safely and radically, with the advantage of maintaining proper digestive function, in patients with gastric cancer located in the upper third of the stomach3–5. Several types of reconstruction have been developed in an effort to improve quality of life6,7, but severe gastro-oesophageal reflux is commonly encountered after any type of reconstruction following proximal gastrectomy. To reduce such reflux symptoms, the authors have performed high segmental gastrectomy for early-stage proximal gastric cancer since 1995. This technique limits the resection of the upper stomach with regional lymphadenectomy while preserving the cardia, and hepatic, pyloric and coeliac branches of the vagal nerve. The purpose of this retrospective study was to evaluate the clinical outcome of high segmental gastrectomy in comparison to that of proximal gastrectomy, in terms of surgical results, postoperative symptoms, nutritional status and survival. Patients and methods The study included 30 consecutive patients who underwent gastrectomy for early gastric cancer located in the upper third of the stomach at the Cancer Institute Hospital, Tokyo, between April 1995 and December 2000. Twelve patients (eight men and four women; mean(s.d.) age 63(9) years) underwent high segmental gastrectomy and 18 (15 men and three women; age 58(8) years) underwent proximal gastrectomy with jejunal interposition. Eligibility criteria for these procedures were: tumour located in the upper third of the stomach, depth of invasion within either mucosal or submucosal tissue, tumour size less than 3·0 cm in diameter, and no evidence of lymph node metastasis confirmed by preoperative multidetector row computed tomography (MDCT). Patients were assigned to either the high segmental gastrectomy or proximal gastrectomy group based on tumour location confirmed before surgery by oesophagogastroscopy or radiography. High segmental gastrectomy was used when the tumour margin was located more than 2·0 cm from the gastro-oesophageal junction (GOJ); proximal gastrectomy was used for tumours within 2·0 cm of the GOJ, but excluding tumours at the junction. The same surgeon performed all laparotomies, in accordance with the guidelines of the Japanese Gastric Cancer Association (JGCA)8. Patients and their families were informed about the possible risks and benefits of the whole clinical trial, and written informed consent was obtained. Demographic details and data on operating time, blood loss and hospital stay after operation were obtained retrospectively from medical records. The clinicopathological features of the tumours were extracted from the pathological reports. Before surgery and during postoperative follow-up for the first year, patients were asked about their reflux symptoms (difficulty with swallowing, heartburn/belching, dyspepsia, chest pain and acid regurgitation) and underwent oesophagogastroscopy to categorize the severity of reflux oesophagitis (classified as none, grade A, B, C or D) according to the Los Angeles classification9. Bodyweight, and serum total protein, albumin and total cholesterol levels, were measured before and after surgery. All patients underwent clinicopathological assessment in accordance with JGCA guidelines8. The last follow-up was February 2005. Surgical techniques The aim of high segmental gastrectomy was to perform limited resection of the proximal third of the stomach with preservation of the cardia, in an attempt to reduce reflux symptoms. To determine the location of the tumour margin, before surgery 0·5 ml CH44 (carbon particle; Mitsubishi Kasei Industry, Tokyo, Japan) was injected via an endoscope into the submucosa of the quadrants encompassing the gastric cancer using an endoscopic puncture needle. All patients underwent laparotomy within 48 h of endoscopy. The proximal margin of the stomach was transected at least 2·0 cm from the tumour margin, while retaining a short segment of cardia. The distal resection line was the same as that for proximal gastrectomy (Fig. 1). Both stumps of the excised portion of the stomach were submitted for frozen-section examination with haematoxylin and eosin staining during the operation. The gastrogastric anastomosis was handsewn using layer-to-layer techniques. For the anastomosis, the outer layer (seromuscular) was sutured with interrupted 4/0 non-absorbable sutures and the inner layer (mucosa and submucosa) was sutured using a continuous 4/0 absorbable suture. Proximal gastrectomy involved resection of the proximal third of the stomach, and the distal oesophagus was anastomosed to the interpositioned jejunum using a circular stapler. Fig. 1 Open in new tabDownload slide a Schematic view of high segmental gastrectomy. The shaded area of the stomach is excised. b Anastomosis is performed between the distal remnant of the stomach and a fundic pouch. c The completed anastomosis after high segmental gastrectomy. High segmental gastrectomy involves resection of approximately one-third of the stomach with preservation of the cardia The grade of lymph node dissection was D1 + alpha, according to the JGCA classification8, in both groups. Perigastric lymph nodes at the right cardial position (no. 1), left cardial position (no. 2), the lesser curvature (no. 3) and along the short gastric artery were excised, along with the left gastroepiploic nodes (no. 4s). The suprapyloric (no. 5) and pyloric (no. 6) lymph nodes were left intact to preserve the right gastric and right gastroepiploic vessels. The area around the descendent ramification of the left gastric artery was not removed completely, so dissection at no. 3 lymph nodes was incomplete for their distal extent. The left gastroepiploic vessels were divided at the roots, but the spleen and pancreas were preserved. The hepatic and pyloric branches of the vagal nerve were preserved, but the branches of the Latarjet nerve were dissected. The posterior vagal trunk was separated from adjacent tissue and taped in place and then pulled to the right so as not to compromise the clearance of regional lymph nodes. Lymph nodes along the left gastric artery (no. 7), the common hepatic artery (no. 8a), around the coeliac axis (no. 9) and at the splenic artery (no. 11d) were excised, and the left gastric vessels were divided at 1·0 cm from the roots to preserve the coeliac branches bifurcating from the posterior vagal trunk (Fig. 2). Pyloric drainage procedures such as pyloroplasty and pyloromyotomy were not used. Fig. 2 Open in new tabDownload slide The posterior vagal trunk is usually palpable as a cord-like structure in adipose tissue surrounded by right and left crura. It is taped and pulled to the patient's right side to cut off the left gastric vessels at 1·0 cm from the roots. CHA, common hepatic artery; SA, splenic artery; LGA, left gastric artery Statistical analysis Statistical analysis was performed using either the χ2 test or Student's t test. Survival rates were calculated by the Kaplan–Meier method. P < 0·050 was considered significant. Results There were no significant differences between the two groups in age or sex, and histopathological features such as tumour invasion, histological type and nodal metastasis (Table 1). Table 1 Comparison of clinicopathological characteristics . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Mean(s.d.) age (years) 63(9) 58(8) 0·190‡ Sex ratio (M:F) 8:4 15:3 0·306 Depth of tumour invasion 0·312  Mucosal 5 11  Submucosal 7 7 Histological type 0·755  Intestinal 8 13  Diffuse 4 5 Lymph node metastasis 0·423  No 12 17  Yes 0 1* . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Mean(s.d.) age (years) 63(9) 58(8) 0·190‡ Sex ratio (M:F) 8:4 15:3 0·306 Depth of tumour invasion 0·312  Mucosal 5 11  Submucosal 7 7 Histological type 0·755  Intestinal 8 13  Diffuse 4 5 Lymph node metastasis 0·423  No 12 17  Yes 0 1* * Involved no. 3 lymph node. † χ2 test unless indicated otherwise; ‡ Student's t test. Open in new tab Table 1 Comparison of clinicopathological characteristics . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Mean(s.d.) age (years) 63(9) 58(8) 0·190‡ Sex ratio (M:F) 8:4 15:3 0·306 Depth of tumour invasion 0·312  Mucosal 5 11  Submucosal 7 7 Histological type 0·755  Intestinal 8 13  Diffuse 4 5 Lymph node metastasis 0·423  No 12 17  Yes 0 1* . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Mean(s.d.) age (years) 63(9) 58(8) 0·190‡ Sex ratio (M:F) 8:4 15:3 0·306 Depth of tumour invasion 0·312  Mucosal 5 11  Submucosal 7 7 Histological type 0·755  Intestinal 8 13  Diffuse 4 5 Lymph node metastasis 0·423  No 12 17  Yes 0 1* * Involved no. 3 lymph node. † χ2 test unless indicated otherwise; ‡ Student's t test. Open in new tab Surgical data are summarized in Table 2. There were no differences in blood loss and hospital stay between the two groups, but mean operating time was significantly shorter for high segmental gastrectomy than for proximal gastrectomy (P = 0·046). One patient developed pulmonary embolism 2 days after proximal gastrectomy and required anticoagulant therapy. There was no anastomotic leakage or stenosis, haemorrhage, pancreatic fistula, intra-abdominal abscess or operative death. The mean number of lymph nodes dissected per patient was similar in the two groups. Table 2 Surgical results . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Operating time (min)* 235(48) 269(39) 0·046 Blood loss (ml)* 466(411) 330(193) 0·249 Dissected lymph nodes* 36(5) 37(6·3) 0·655 Hospital stay (days)* 15(3) 17(3) 0·095 Complications 0·423‡  No 12 17  Yes 0 1 . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Operating time (min)* 235(48) 269(39) 0·046 Blood loss (ml)* 466(411) 330(193) 0·249 Dissected lymph nodes* 36(5) 37(6·3) 0·655 Hospital stay (days)* 15(3) 17(3) 0·095 Complications 0·423‡  No 12 17  Yes 0 1 * Values are mean(s.d.). † Student's t test unless indicated otherwise; ‡ χ2 test. Open in new tab Table 2 Surgical results . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Operating time (min)* 235(48) 269(39) 0·046 Blood loss (ml)* 466(411) 330(193) 0·249 Dissected lymph nodes* 36(5) 37(6·3) 0·655 Hospital stay (days)* 15(3) 17(3) 0·095 Complications 0·423‡  No 12 17  Yes 0 1 . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P† . Operating time (min)* 235(48) 269(39) 0·046 Blood loss (ml)* 466(411) 330(193) 0·249 Dissected lymph nodes* 36(5) 37(6·3) 0·655 Hospital stay (days)* 15(3) 17(3) 0·095 Complications 0·423‡  No 12 17  Yes 0 1 * Values are mean(s.d.). † Student's t test unless indicated otherwise; ‡ χ2 test. Open in new tab Reflux symptoms were not a significant problem for patients in either group before surgery. The incidence of reflux oesophagitis and nutritional data at 1 year after operation are shown in Table 3. Reflux symptoms were observed on physiological examination in one of 12 patients in the high segmental gastrectomy group and nine of 18 patients in the proximal gastrectomy group (P = 0·016). Endoscopically detected gastro-oesophagitis was more common after proximal gastrectomy (P < 0·001). In both groups, levels of laboratory variables such as serum total protein, albumin and total cholesterol levels had recovered to preoperative values by 1 year after surgery. Bodyweight decreased slightly in most patients Mean weight loss was 7·4 per cent in the high segmental gastrectomy group and 11·2 per cent in the proximal gastrectomy group (P = 0·122). Table 3 Postoperative course . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P§ . Reflux symptoms 0·016  No 11 9  Yes† 1 9 Severity of oesophagitis‡ < 0·001  None 10 4  Grade A 2 13  Grade B 0 0  Grade C 0 1  Grade D 0 0 Weight loss (%)* 7(6) 11(4) 0·122¶ Blood chemistry (% preoperative value)  Total protein 104 104 0·981  Albumin 103 105 0·443  Total cholesterol 103 108 0·257 . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P§ . Reflux symptoms 0·016  No 11 9  Yes† 1 9 Severity of oesophagitis‡ < 0·001  None 10 4  Grade A 2 13  Grade B 0 0  Grade C 0 1  Grade D 0 0 Weight loss (%)* 7(6) 11(4) 0·122¶ Blood chemistry (% preoperative value)  Total protein 104 104 0·981  Albumin 103 105 0·443  Total cholesterol 103 108 0·257 * Values are mean(s.d.). † Symptoms more than twice a week. ‡ Los Angeles classification based on endoscopic findings. § χ2 test unless indicated otherwise; ¶ Student's t test. Open in new tab Table 3 Postoperative course . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P§ . Reflux symptoms 0·016  No 11 9  Yes† 1 9 Severity of oesophagitis‡ < 0·001  None 10 4  Grade A 2 13  Grade B 0 0  Grade C 0 1  Grade D 0 0 Weight loss (%)* 7(6) 11(4) 0·122¶ Blood chemistry (% preoperative value)  Total protein 104 104 0·981  Albumin 103 105 0·443  Total cholesterol 103 108 0·257 . High segmental gastrectomy (n = 12) . Proximal gastrectomy (n = 18) . P§ . Reflux symptoms 0·016  No 11 9  Yes† 1 9 Severity of oesophagitis‡ < 0·001  None 10 4  Grade A 2 13  Grade B 0 0  Grade C 0 1  Grade D 0 0 Weight loss (%)* 7(6) 11(4) 0·122¶ Blood chemistry (% preoperative value)  Total protein 104 104 0·981  Albumin 103 105 0·443  Total cholesterol 103 108 0·257 * Values are mean(s.d.). † Symptoms more than twice a week. ‡ Los Angeles classification based on endoscopic findings. § χ2 test unless indicated otherwise; ¶ Student's t test. Open in new tab No patient in either group developed recurrence. The overall 5-year survival rate was 96 per cent, 100 per cent after high segmental gastrectomy and 93 per cent after proximal gastrectomy. Discussion Proximal gastrectomy is considered an appropriate treatment for early-stage proximal gastric cancer, and various gastric reconstruction operations have been advocated3–5. Oesophagogastric reconstruction has frequently been used because it is simple, allows the physiological function of the remnant stomach to be preserved, and has an overall survival rate similar to that of total gastrectomy3,10,11. However, severe gastro-oesophagitis is common, especially when the anastomosis is performed above the diaphragm12. Several authors have reported that a single or double jejunal interposition is a satisfactory gastric substitute in terms of capacity for food, and minimal postoperative signs and symptoms of gastro-oesophagitis5,6. Reflux gastro-oesophagitis seems to be a problem common to numerous types of reconstruction that have been used in conjunction with proximal gastrectomy4–7. In the present study surgical outcome following high segmental gastrectomy for early gastric cancer located in the upper third of the stomach was superior to that after proximal gastrectomy with short segmental jejunal interposition. Although the two groups of patients were not matched, half of those who had proximal gastrectomy developed reflux symptoms, whereas these were rarely encountered after high segmental gastrectomy. These preliminary results suggest that high segmental gastrectomy does have an impact in controlling reflux symptoms. The technique of segmental gastrectomy was first reported by Wangensteen et al.13–15 to prevent the loss of digestive and reservoir function in patients with peptic ulcer. Ohwada et al.16 modified the procedure for early gastric cancer located in the middle part of the stomach to limit further both the amount of stomach excised and the number of lymph nodes dissected. They reported that segmental gastrectomy was preferable in terms of quality of life and curability. The present authors have extended the procedure to treat early gastric cancer located in the upper third of the stomach. The ascending and some of the descending branches of the left gastric vessels are divided to maximize lymph node clearance in this procedure. The proximal remnant stomach is vascularized by the branches of the left inferior phrenic artery and the posterior gastric artery, while blood supply to the distal remnant stomach is maintained by a network between the right gastric artery and the right gastroepiploic artery. The ascending branches and some of the descending branches of the left gastric vessels can be divided without compromising blood flow to the remnant stomach. Accurate preoperative diagnosis of regional lymph node metastases is essential in the selection of limited gastrectomy to minimize the risks of complications without increasing the rate of recurrence17,18. In this study, all patients underwent preoperative MDCT within 2 weeks of surgery. MDCT using thinner slices has been shown to identify the presence of lymph node metastasis as accurately as intraoperative assessment in patients with early gastric cancer19. Only one patient in the present study had lymph node metastasis in the perigastric region (no. 3). Limited lymphadenectomy (D1 + alpha) was judged to be sufficient, and was associated with a high survival rate (96 per cent) and low morbidity. A number of gastric reconstruction operations have been noted to improve the postoperative nutritional state4–7. Hinoshita et al.20 reported that postoperative levels of nutritional variables such as serum total protein, total cholesterol and cholinesterase were all significantly better after proximal gastrectomy than total gastrectomy. Furukawa et al.21 noted that the average weight loss after proximal gastrectomy was less than that following total gastrectomy. In this study, mean weight loss was 11·2 per cent after proximal gastrectomy, almost identical to that reported previously4,5. The recovery of blood chemicals after operation was similar after high segmental gastrectomy and proximal gastrectomy, although we could find no statistically significant differences, mean percentage weight loss was better in the high segmental gastrectomy group. Preservation of the cardia may not only contribute to reducing gastro-oesophageal reflux but also promote the concentration of pancreatic juices and bile in the gastric content. A limitation of this procedure is that it is not applicable to tumours located close to the GOJ. However, for early gastric cancers in the upper third of the stomach with an oral margin of 2 cm or more from the GOJ, high segmental gastrectomy appears useful in preventing reflux symptoms. It also has the advantage of being more straightforward than proximal gastrectomy, as judged by the shorter operating time. A more detailed prospective study is now required to elucidate factors relevant to reflux symptoms. References 1 Ohta H , Noguchi Y, Takagi K, Nishi M, Kajitani T, Kato Y. Early gastric carcinoma with special reference to macroscopic classification . Cancer 1987 ; 60 : 1099 – 1106 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Nishi M , Ishihara S, Nakajima T, Ohta K, Ohyama S, Ohta H. Chronological changes of characteristics of early gastric cancer and therapy: experience in the Cancer Institute Hospital of Tokyo, 1950–1994 . 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Ann Surg Oncol 1998 ; 5 : 338 – 341 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Clinical outcome of high segmental gastrectomy for early gastric cancer in the upper third of the stomach
JO - British Journal of Surgery
DO - 10.1002/bjs.5388
DA - 2006-07-17
UR - https://www.deepdyve.com/lp/oxford-university-press/clinical-outcome-of-high-segmental-gastrectomy-for-early-gastric-5nVKoeImHs
SP - 975
EP - 980
VL - 93
IS - 8
DP - DeepDyve
ER -