Effect of forearm and posterior wall anastomosis on gastroesophageal reflux in proximal gastrectomy patients

Abstract

BACKGROUND

Proximal gastrectomy for gastric cancer often leads to postoperative gastroesophageal reflux (GER). This study compares the impact of forearm anastomosis and posterior wall anastomosis techniques on GER in patients undergoing this procedure.

AIM

To identify the most effective method for reducing reflux symptoms while preserving gastrointestinal integrity and nutritional status.

METHODS

A retrospective evaluation was conducted on 60 patients who underwent proximal gastrectomy between December 2020 and December 2023, divided equally into two groups based on the anastomosis technique used (forearm or posterior wall). GER symptoms were assessed using the GER disease questionnaire (GerdQ) preoperatively and on the first postoperative day. Biochemical markers [diamine oxidase (DAO), D-lactic acid, and endotoxin (ETX)] and nutritional indicators [serum ferritin (SF), prealbumin (PA), and albumin (ALB)] were measured to evaluate gastrointestinal barrier function and nutritional status.

RESULTS

Both groups showed significant improvements in GerdQ scores and reflux symptom scores post-treatment, with the observation group exhibiting greater reductions. Biochemical markers indicated enhanced gastrointestinal barrier function post-treatment in both groups, with notable increases in DAO, D-lactic, and ETX levels. Nutritional status indicators also demonstrated significant changes, with reductions in SF, PA, and ALB levels, suggesting an impact of treatment on inflammatory and nutritional status.

CONCLUSION

The forearm anastomosis technique appears to be more effective in reducing GER symptoms and preserving gastrointestinal health in patients undergoing proximal gastrectomy for gastric cancer compared to the posterior wall anastomosis technique. These preliminary findings advocate for further research to confirm the benefits and potentially standardize Forearm Anastomosis in surgical practice for gastric cancer.

Key Words: Proximal gastrectomy; Gastroesophageal reflux; Forearm anastomosis; Posterior wall anastomosis; Gastric cancer

Core Tip: This manuscript provides a comprehensive analysis of two distinct anastomosis techniques and their effects on postoperative gastroesophageal reflux (GER), an issue of paramount importance in the surgical management of gastric cancer. Our study embarked on a meticulous comparative evaluation between forearm anastomosis and posterior wall anastomosis techniques, focusing on their efficacy in mitigating GER symptoms and their impact on the gastrointestinal barrier function and nutritional status of the patient’s post-proximal gastrectomy. Through rigorous assessment and detailed analysis, our findings illuminate the superior benefits of the Forearm Anastomosis technique, not only in reducing GER symptoms but also in preserving gastrointestinal health.

INTRODUCTION

Proximal gastric cancer, a subtype affecting the upper portion of the stomach and the gastroesophageal junction, necessitates a specialized surgical approach known as proximal gastrectomy[1]. Unlike total gastrectomy, which involves the complete removal of the stomach, or distal gastrectomy, which involves the removal of the lower portion of the stomach, proximal gastrectomy specifically targets the upper segment of the stomach, preserving much of the gastric body and pylorus. This approach is aimed at maintaining gastrointestinal function, particularly preserving the patient’s nutritional status and digestive capacity, while ensuring adequate oncological resection of the cancerous tissue[2,3]. The primary challenge in proximal gastrectomy lies in balancing oncological safety with the preservation of stomach function, which is a critical factor in determining postoperative quality of life.

The postoperative phase following proximal gastrectomy, however, is frequently overshadowed by a spectrum of complications, among which gastroesophageal reflux (GER) disease (GERD) emerges as particularly prevalent and debilitating. GERD, characterized by the retrograde flow of gastric contents into the esophagus, manifests through symptoms such as heartburn, regurgitation, and potential esophageal mucosal damage[4,5]. The incidence of GERD after proximal gastrectomy has been reported to range from 20% to 60%, with some studies suggesting that nearly half of patients experience moderate to severe symptoms postoperatively[6]. The pathophysiology of GERD post-gastrectomy is multifaceted, with the surgical reconstruction of the digestive tract playing a central role in the development and severity of reflux symptoms. Traditional reconstruction techniques, while effective in re-establishing gastrointestinal continuity, often fall short in preventing the backflow of acidic gastric contents into the esophagus, leading to a high incidence of GERD.

In light of the constraints of traditional reconstructive approaches, there is increasing interest in investigating alternate anastomosis techniques designed to diminish the occurrence of postoperative GERD. The forearm anastomosis and posterior wall anastomosis procedures have attracted interest for their novel methodology in gastroesophageal junction restoration. The forearm anastomosis procedure entails constructing a conduit from the vascularized tissue of the forearm, subsequently anastomosed to the residual stomach and esophagus. This approach is posited to offer a more natural angle and resistance to the retrograde passage of stomach contents[7]. The posterior wall anastomosis approach entails the direct connection of the posterior wall of the residual stomach to the esophagus, which may diminish stress at the anastomotic site and hence lower the risk of reflux[8]. In comparison to traditional anastomosis techniques, both the forearm anastomosis and posterior wall anastomosis techniques have demonstrated promising efficacy in reducing the incidence and severity of postoperative GER, as reported in previous studies[9-11]. The primary objective of this research is to evaluate the impact of these two anastomosis techniques on both the incidence and severity of GER (GERD), as well as postoperative quality of life in patients undergoing proximal gastrectomy for gastric cancer. By comparing the outcomes associated with the forearm and posterior wall anastomosis techniques, this study aims to identify the more effective surgical approach in reducing GERD symptoms while simultaneously preserving gastrointestinal integrity and improving overall postoperative well-being.

MATERIALS AND METHODS

Study design

A comprehensive retrospective analysis was performed at our hospital to evaluate the effectiveness of the forearm anastomosis technique and its influence on GER following curative proximal gastrectomy for gastric cancer. This study extended from December 2020 to December 2023, concentrating on a group of 30 patients who received digestive tract restoration utilizing the forearm anastomosis method. The people were assigned as the case group for comprehensive analysis. A control group was created for a thorough comparison, consisting of 30 patients who received the posterior wall anastomosis procedure over the same period. This method established a baseline comparability between the two groups, facilitating a nuanced comprehension of the varying effects of these anastomosis procedures on postoperative outcomes, particularly GER. Informed consent was secured from all study participants, highlighting the voluntary aspect of their involvement and the clear disclosure of the study's aims and methods. The research technique, encompassing the study's objectives and methods, was rigorously evaluated by the ethical committee of our institution.

Inclusion and exclusion criteria

Eligible participants for this study were individuals aged 18 years and older, diagnosed with proximal gastric cancer via histopathological examination, who underwent curative proximal gastrectomy utilizing either forearm anastomosis or posterior wall anastomosis techniques between December 2020 and December 2023. All participants were mandated to submit written informed consent, confirming their comprehension and willing involvement in the study.

The study excluded patients having a history of prior gastric surgery due to its potential impact on the outcomes of proximal gastrectomy and anastomosis procedures. Individuals with metastatic illness or stomach cancer unsuitable for curative resection were also excluded. Individuals with significant concurrent medical issues that made them unfit for surgery, including advanced heart illness, uncontrolled diabetes, or severe chronic obstructive pulmonary disease, were likewise eliminated. Additionally, patients who underwent chemotherapy or radiotherapy for stomach cancer before to the operation were excluded to guarantee the integrity of the evaluation of the anastomosis techniques' efficacy.

Surgical techniques

The forearm anastomosis technique was employed for digestive tract restoration in the observation group after radical proximal gastrectomy. The stomach remnant was turned 45 degrees to the right, enabling the insertion of a trocar through a predetermined hole. The trocar's needle was precisely positioned to penetrate the front wall of the gastric remnant, 5 cm from the cut edge, ensuring correct alignment with the reserved esophageal stump for a successful single fire. A gastric tube was subsequently placed via the pylorus into the duodenum. The jejunum was located 30 cm distal to the Treitz ligament and sealed with a 45-mm disposable intraluminal stapler, maintaining an aperture for later manual suturing around the esophagus, gastrointestinal mucosa, and anastomosis site to guarantee closure. The stomach's curvature was secured next to the left diaphragmatic crura, forming an artificial gastric fundus. Hemostasis was carefully attained, succeeded by a sterile saline irrigation of the peritoneal cavity. A rubber drainage tube was positioned at the anastomosis site, extending through Winslow's foramen and along the right colic gutter, conforming to the downward trajectory of the right puncture site. The abdominal cavity was then closed in layers.

The posterior wall anastomosis procedure was utilized in the control group. Like the observation group, this entailed a major proximal gastrectomy, succeeded by the direct placement of a trocar via the designated opening. The needle was calibrated to penetrate the posterior wall, 5 cm from the resection edge of the stomach remnant. The following procedures, such as the insertion of the gastric tube, formation of an artificial gastric fundus, and drainage, were similar to those executed in the observation group, maintaining procedural uniformity and comparability between the two groups.

Data collection and evaluation criteria

This study employed a comprehensive set of observational indicators and evaluation criteria to assess the outcomes and impact of forearm anastomosis and posterior wall anastomosis techniques on GER symptoms in patients undergoing proximal gastrectomy for gastric cancer.

GER symptom assessment: GER symptoms in both cohorts were assessed preoperatively and on the first postoperative day utilizing the GERD questionnaire (GerdQ). The GerdQ comprises six items, each rated from 0 to 3, resulting in a possible total score of 18. Elevated scores signify increased symptom severity. Simultaneously, a bespoke scale created by our institution, encompassing dimensions of regurgitation, retrosternal pain, belching, and heartburn, was employed. Each dimension was classified as severe (6 points), moderate (4 points), mild (2 points), or none (0 points), with the scale exhibiting a reliability coefficient of 0.801, signifying strong dependability.

Biochemical markers: Venous blood samples (5 mL) were obtained from the upper limbs of patients in both groups before to surgery and on the first postoperative day. The samples underwent centrifugation at 3000 rpm for 10 minutes, and the resultant supernatant serum was utilized for analysis. Diamine oxidase (DAO) and D-lactic acid levels were determined by a colorimetric test kit, whilst endotoxin (ETX) levels were assessed using the limulus amebocyte lysate chromogenic substrate method. The test kits were obtained from Shanghai Yu Bo Biotech Co., Ltd., and all protocols were meticulously followed in accordance with the manufacturer's guidelines.

Serum protein levels and nutritional status: Preoperative and postoperative day one fasting venous blood samples (5 mL) were obtained from patients, centrifuged at 3000 rpm for 10 minutes, and the serum was preserved at -70 °C for subsequent analysis. Serum ferritin (SF) levels were assessed utilizing a BS-820 automatic biochemical analyzer employing the ferrozine method. Prealbumin (PA) concentrations were quantified via turbidimetry, while albumin (ALB) concentrations were evaluated using the bromocresol green method. The assay kits were obtained from Shanghai Jing Kang Bio-Tech Co., Ltd., and tests were conducted in accordance with the kit instructions. Additionally, patients' weight and height were measured to calculate the body mass index (BMI) using the formula: BMI = weight (kg)/height² (m²).

Statistical analysis

Statistical analyses in this study were performed using SPSS (Version 27.0), starting with the categorization of data into quantitative and categorical groups, and subsequently conducting normality checks to determine distribution patterns. Group differences in normally distributed quantitative data were assessed using independent t-tests, with findings reported as means and standard deviations. Quantitative data that were not normally distributed were evaluated using the Mann-Whitney U test, with medians and interquartile ranges [M (P25, P75)] given. Categorical data were evaluated with χ² testing, reported as frequencies and percentages. Significance was evaluated at a P value < 0.05, ensuring stringent hypothesis testing.

RESULTS

Participant analysis

The control group consisted of 18 male and 12 female patients, aged between 25 and 68 years (mean age: 50.12 ± 5.16 years). The tumor diameters ranged from 1.1 to 4.2 cm, with a mean diameter of 3.16 ± 0.38 cm. The BMI ranged from 20.3 to 25.6 kg/m², with a mean of 23.12 ± 1.38 kg/m². The TNM staging distribution comprised 16 cases at stage IA, 8 instances at stage IB, and 6 cases at stage IIA. The observation group comprised 17 male and 13 female patients, aged 26 to 67 years (mean age: 49.16 ± 6.58 years). Tumor sizes varied from 1.2 to 4.1 cm, with a mean of 2.91 ± 0.35 cm. The BMI readings ranged from 20.6 to 25.8 kg/m², with a mean of 23.16 ± 1.26 kg/m². In terms of TNM staging, there were 17 instances classified as stage IA, 7 cases as stage IB, and 6 cases as stage IIA. Statistical analysis indicated no significant variations in the demographic and clinical characteristics between the two groups (P > 0.05), demonstrating homogeneity in the baseline data and confirming the comparability of post-treatment results between the observation and control groups.

Comparative evaluation of GerdQ scores and reflux symptom scores pre- and post-treatment in observation and control groups

The study results highlight substantial enhancements in GERD symptoms and GerdQ scores following therapy in both the observation and control groups, as demonstrated by the statistical analyses. Both groups showed significant reductions in GerdQ scores and reflux symptom scores post-treatment; however, the observation group shown a more substantial improvement than the control group. Following therapy, the observation group exhibited a dramatic reduction in GerdQ scores, with mean scores declining from 14.66 to 7.32, indicating a significant amelioration of GERD symptoms. The control group experienced an improvement as well, with GerdQ values decreasing from 14.62 to 10.35, though at a lower degree than the observation group. The disparity in post-treatment GerdQ ratings between the two groups was statistically significant, underscoring the enhanced efficacy of the treatment method employed in the observation group. The examination of certain reflux symptoms, such as regurgitation, retrosternal discomfort, and belching, demonstrated notable post-treatment enhancements in each cohort. The observation group exhibited a significant decrease in symptom severity, with post-treatment scores reflecting a low presence of symptoms. Conversely, although the control group exhibited improvements in these symptoms, the degree of reduction was less significant than that of the observation group. The statistical analysis of pre- and post-treatment scores within each group shown substantial differences, highlighting the therapies' efficacy in alleviating GERD symptoms. Inter-group comparisons underscored the superior outcomes in the observation group, exhibiting reduced post-treatment scores for all assessed symptoms relative to the control group (Table 1).

Table 1 Pre- and post-treatment gastroesophageal reflux disease questionnaire scores and reflux symptom scores in observation and control groups, mean ± SD.

Measurement	Observation group	Control group	t value	P value
GerdQ score pre-treatment	14.66 ± 1.66	14.62 ± 1.71	0.08	0.95
GerdQ score post-treatment	7.32 ± 1.101	10.35 ± 1.371	7.191	< 0.001
Reflux symptom pre-treatment	3.27 ± 1.17	3.24 ± 1.10	0.09	0.94
Reflux symptom post-treatment	1.13 ± 0.641	1.97 ± 0.901	3.168	0.002
Regurgitation pre-treatment	1.97 ± 0.88	1.96 ± 0.84	0.04	0.98
Regurgitation post-treatment	0.93 ± 0.221	1.42 ± 0.471	3.971	< 0.001
Retrosternal pain pre-treatment	1.64 ± 0.58	1.65 ± 0.59	0.06	0.96
Retrosternal pain post-treatment	0.63 ± 0.251	1.18 ± 0.341	5.446	< 0.001
Belching pre-treatment	2.17 ± 0.64	2.20 ± 0.59	0.16	0.88
Belching post-treatment	0.66 ± 0.251	1.40 ± 0.331	8.273	< 0.001

¹Comparisons within the same group pre- and post-treatment are marked with an asterisk, indicating a statistically significant difference with a P value less than 0.05.

GerdQ: Gastroesophageal reflux disease questionnaire.

Comparative analysis of gastrointestinal barrier function markers before and after treatment

The research evaluated the impact of gastrointestinal therapies on biomarkers reflecting intestinal health and microbial equilibrium, specifically DAO, D-lactic Acid, and ETX, in both the observation and control cohorts. Post-treatment assessments indicated substantial increases in all evaluated biomarkers, underscoring the physiological effects of the therapeutic measures. In the observation group, DAO levels rose from 1.53 IU/L to 2.25 IU/L, while the control group exhibited a comparable increase, with levels escalating from 1.56 IU/L to 3.18 IU/L, signifying improved enzymatic activity associated with intestinal mucosal integrity following treatment. D-lactic acid levels, indicative of metabolic byproducts from gut microbiota, exhibited a significant rise in both groups, implying alterations in microbial metabolism. Significant changes were noted in ETX levels, which more than quadrupled after treatment in both groups, indicating modifications in gut microbial ETX levels (Table 2).

Table 2 Diamine oxidase, D-lactic, and endotoxin levels pre- and post-treatment in observation and control groups.

Measurement	Pre-treatment observation	Post-treatment observation	Pre-treatment control	Post-treatment control	t value	P value
DAO (IU/L)	1.53 ± 0.24	2.25 ± 0.501	1.56 ± 0.28	3.18 ± 0.621	5.409	< 0.01
D-lactic (mg/L)	2.78 ± 0.56	3.44 ± 0.761	2.72 ± 0.54	4.29 ± 0.871	3.357	< 0.01
ETX (EU/mL)	0.41 ± 0.14	1.36 ± 0.331	0.39 ± 0.16	1.71 ± 0.451	3.451	< 0.01

¹Comparisons within the same group pre- and post-treatment are marked with an asterisk, indicating a statistically significant difference with a P value less than 0.05.

DAO: Diamine oxidase; ETX: Endotoxin.

Comparative evaluation of nutritional status indicators before and after treatment

The study's results indicate substantial alterations in nutritional and inflammatory indicators, including SF, PA, and ALB, after treatment in both the observation and control groups. The pre-treatment levels of these markers were similar across the groups, giving a baseline for assessing the treatment's effect. Post-treatment analysis indicated a reduction in SF levels from 94.67 µg/L to 82.54 µg/L in the observation group, whereas the control group exhibited a more significant decline from 95.40 µg/L to 74.28 µg/L, suggesting a possible decrease in inflammation or iron reserves. Likewise, PA levels, reflecting nutritional status and inflammation, diminished in both cohorts during treatment, with the observation group decreasing from 254.82 mg/L to 236.44 mg/L and the control group from 255.94 mg/L to 220.18 mg/L. ALB levels, indicative of nutritional status and chronic inflammation, exhibited a notable decline, especially in the control group, where levels diminished from 39.98 g/L to 35.08 g/L following therapy. These modifications indicate an effect of the treatment on nutritional and inflammatory state, with the control group displaying more significant changes (Table 3).

Table 3 Levels of serum ferritin, prealbumin, and albumin pre- and post-treatment in observation and control groups.

Measurement	Pre-treatment observation	Post-treatment observation	Pre-treatment control	Post-treatment control	t value	P value
SF (µg/L)	94.67 ± 10.90	82.54 ± 11.671	95.40 ± 10.99	74.28 ± 9.661	2.519	0.016
PA (mg/L)	254.82 ± 18.31	236.44 ± 17.881	255.94 ± 18.33	220.18 ± 14.791	3.237	< 0.01
ALB (g/L)	40.54 ± 4.40	38.73 ± 3.65	39.98 ± 3.99	35.08 ± 3.651	4.173	< 0.01

¹Comparisons within the same group pre- and post-treatment are marked with an asterisk, indicating a statistically significant difference with a P value less than 0.05.

SF: Serum ferritin; PA: Prealbumin; ALB: Albumin.

DISCUSSION

Proximal gastrectomy for gastric cancer carries a significant risk of postoperative GERD, which can severely impact patient quality of life[12,13]. Various anastomosis techniques, including forearm and posterior wall anastomosis, have been explored to mitigate this complication[14,15]. The aim of this study is to compare the efficacy of these two techniques in reducing GERD symptoms, preserving gastrointestinal integrity, and improving overall postoperative well-being in patients undergoing proximal gastrectomy for gastric cancer. Through this comparison, the study seeks to identify the more effective surgical approach in minimizing reflux while optimizing long-term recovery[16,17]. This study provides novel insights into the comparative efficacy of the Forearm Anastomosis technique vs the posterior wall anastomosis technique in mitigating GERD symptoms following curative proximal gastrectomy for gastric cancer. The key innovation lies in its prospective analysis of gastrointestinal barrier function, microbial balance, and nutritional status using objective biomarkers such as DAO, D-lactic acid, and ETXs, alongside traditional GERD assessments. Notably, the Forearm Anastomosis technique demonstrated superior outcomes in reducing GERD symptoms, as evidenced by significant improvements in GerdQ scores and reflux symptom severity. Additionally, the study highlights the potential for both techniques to influence intestinal integrity and nutritional status, with the forearm anastomosis showing more favorable results in certain biomarkers. Clinically, these findings underscore the importance of surgical technique selection in enhancing postoperative quality of life, particularly in reducing reflux complications and improving long-term gastrointestinal health and nutritional recovery post-gastrectomy. This research contributes valuable evidence for optimizing surgical strategies in gastric cancer care.

This study's outcomes yield valuable data regarding the effects of therapeutic interventions on GERD symptoms, gastrointestinal barrier function, and nutritional status in patients receiving therapy for gastric-related diseases. The notable enhancements in GERD symptoms and GerdQ scores following therapy, especially in the observation group, highlight the effectiveness of the implemented therapeutic strategy. The significant reduction in GerdQ scores from 14.66 to 7.32 in the observation group indicates a considerable improvement in GERD symptoms, likely due to the targeted intervention techniques utilized, which may have more effectively restored gastroesophageal junction integrity and diminished acid reflux occurrences. The significant improvements in gastrointestinal barrier function markers, such as DAO, D-Lactic Acid, and ETX, following therapy in both groups, indicate a favorable transition towards enhanced intestinal health and microbial equilibrium. The increase in DAO levels following therapy suggests improved mucosal barrier integrity, likely resulting from the therapeutic enhancement of mucosal defense mechanisms against luminal antigens and pathogens[18]. The elevation of D-lactic levels in both groups indicates a modification in microbial fermentation processes, potentially signifying alterations in gut microbiota composition or activity. The significant elevation in ETX levels following therapy may suggest enhanced bacterial translocation or alterations in gut barrier permeability, warranting additional examination of the consequences of these changes on patient health. The research also emphasizes notable alterations in nutritional and inflammatory indicators, specifically SF, PA, and ALB, subsequent to treatment. The drop in SF levels following therapy may indicate less inflammation or changes in iron metabolism, potentially linked to the therapeutic approaches utilized[19,20]. The reduction in PA and ALB levels following therapy in both groups indicates an effect of the treatment on the patients' nutritional and inflammatory condition. The significant reductions in these markers within the control group may suggest a varied response to the treatment technique employed, maybe incorporating more aggressive or comprehensive therapeutic measures that could have unintentionally influenced nutritional status.

The reported results and their fundamental mechanisms can be situated within the larger context of stomach cancer treatment and management. The restoration of gastroesophageal junction integrity and the enhancement of gastrointestinal barrier function are essential for improving patient outcomes and quality of life following treatment. The changes in nutritional and inflammatory markers highlight the necessity of holistic patient care, which includes both the specific treatment of the primary ailment and the management of related systemic repercussions. The processes behind these reported changes require additional examination. The relationship among therapeutic interventions, gastrointestinal health, microbial equilibrium, and overall nutritional and inflammatory conditions is intricate[21]. The treatments likely influenced both the local gastric environment and had systemic effects, potentially mediated by gut-brain axis interactions, modifications in gut microbiota composition and function, and changes in systemic inflammatory pathways.

The observed elevation in D-lactic acid and ETX levels post-treatment, while seemingly contradictory to improved gastrointestinal barrier function, can be explained by postoperative physiological changes. D-lactic acid, a byproduct of gut bacterial fermentation, reflects shifts in microbial composition following surgical alterations like anastomosis. Similarly, increased ETX levels, indicative of bacterial translocation due to transient intestinal permeability changes, are common in the early postoperative phase after major gastrointestinal surgery. These fluctuations are not indicative of long-term barrier dysfunction but rather transient disruptions in gut integrity. The improvement in DAO levels, however, suggests a longer-term restoration of gastrointestinal barrier function, reinforcing the overall trend of recovery despite short-term microbiota shifts and permeability changes. In terms of surgical execution, all procedures were performed by surgeons with at least five years of clinical experience, minimizing potential biases related to surgical proficiency. A standardized protocol was strictly adhered to for both the FA and posterior wall anastomosis techniques, ensuring procedural consistency and the reliability of comparative analysis. No significant baseline differences were noted between the two groups, strengthening the validity of our findings. While the FA group exhibited substantial improvements in GERD symptoms, this did not immediately correlate with changes in nutritional markers such as SF, PA, and ALB. The complexity of the FA technique may delay nutritional recovery due to altered gastrointestinal dynamics, whereas the posterior wall anastomosis group demonstrated a more rapid recovery in nutritional status. This suggests that while FA effectively mitigates GERD symptoms, its impact on nutritional recovery is more gradual, likely due to the intricacies of the reconstructive process and postoperative inflammatory response.

This study's limitations include a relatively small sample size, which may impact the generalizability of the findings. Additionally, the retrospective nature of the analysis could introduce selection biases and limit the ability to establish causality. The study also focused on short-term outcomes, leaving long-term effects of the anastomosis techniques on GER and patient quality of life unexplored. Furthermore, the limited postoperative assessment period (only on the first postoperative day) restricts our understanding of the sustained impact of the anastomosis techniques. Future studies should aim to expand the sample size and employ a prospective design to validate these findings. Long-term follow-up is crucial to assess the durability of the anastomosis techniques' effects on reflux control and overall survival rates. Additionally, incorporating extended follow-up periods will offer a more comprehensive understanding of the long-term effects on GERD symptoms, nutritional status, and overall patient outcomes. Investigating patient-reported outcomes will provide a more complete evaluation of the impact on quality of life.

CONCLUSION

In conclusion, the application of the Forearm Anastomosis technique in radical proximal gastrectomy for gastric cancer might demonstrate promising outcomes. It could effectively alleviate GER symptoms, enhance gastrointestinal barrier function, and improve nutritional status in patients. Further research is warranted to validate these findings and establish the technique as a standard practice in surgical management.