Feasibility and outcomes of pylorus-preserving gastrectomy in selected cases of upper-third early gastric cancer: a comparative analysis with proximal gastrectomy

This study compared short-term surgical, oncological, and nutritional outcomes of pylorus-preserving gastrectomy (PPG) versus proximal gastrectomy (PG) in patients with early gastric cancer located in the upper third of the stomach, specifically in borderline cases where both procedures are feasible. Patients with clinical T1N0M0 gastric adenocarcinoma in the gray zone (the endoscopically ambiguous area between the upper and middle thirds, with the proximal tumor border at least 3 cm distal to the esophagogastric junction) were retrospectively identified at Seoul National University Hospital (2014–2022). Eligibility was determined from preoperative endoscopy alone. One-to-one optimal propensity score matching on age, sex, body mass index (BMI), tumor size, tumor location and surgical approach, exact on tumor location, yielded 31 pairs. The principal outcome, designated a posteriori, was the percentage change in BMI at 12 months. Outcomes were compared at 6 and 12 months postoperatively. All model covariates achieved a standardized mean difference below 0.10. Morbidity was 9.7% in both groups (Clavien–Dindo grade IIIa: 1 vs. 2 patients). R0 resection was achieved in every patient. The proximal margin was shorter after PPG (median 1.5 vs. 2.8 cm, p < 0.001) and the distal margin longer (5.2 vs. 3.5 cm, p = 0.002); retrieved lymph nodes did not differ significantly (34.0 vs. 27.0, p = 0.070). Lymph node metastasis occurred in one PG patient (station 3a) and no PPG patient; no recurrence or death occurred (recurrence 0 of 31; 95% CI 0–11.2%) over a median follow-up of 60 (PPG) and 46 (PG) months. BMI reduction was smaller after PPG at 6 months (− 8.80% vs. −12.77%, p = 0.026) and 12 months (− 9.63% vs. −13.96%, p = 0.031; difference + 4.33% points, 95% CI + 0.42 to + 8.24). Changes in total protein and albumin favored PPG without reaching significance in the matched cohort ( p = 0.074 and p = 0.083 at 6 months). In carefully selected patients with gray-zone upper-third early gastric cancer, PPG achieved R0 resection in every patient and was associated with less postoperative weight loss than PG, without evidence of compromised short-term oncological adequacy.