An outermost-layer-oriented medial approach to facilitate margin-negative distal transection in gastric cancer with duodenal invasion: a single-centre retrospective cohort study.

BACKGROUND

Gastric cancer with duodenal invasion (Duo+) presents a distinct surgical challenge because adequate distal-margin clearance must be achieved without compromising duodenal stump safety. Standardised laparoscopic strategies for this setting remain poorly defined.

METHODS

In this single-centre retrospective cohort study, we evaluated the technical feasibility and observed outcomes of an integrated extended-mobilisation and margin-control strategy in 500 patients undergoing laparoscopic distal gastrectomy with D2 lymphadenectomy for stage II-III gastric adenocarcinoma. The cohort included 90 patients with duodenal invasion (Duo+) and 410 without duodenal invasion (Duo-). In Duo+ cases, the strategy comprised extended duodenal-bulb mobilisation, optimisation of stapler angulation, routine intraoperative frozen-section diagnosis of the distal margin, and reinforcement of the duodenal stump. Outcomes in the Duo- group were reported to provide clinical context rather than to estimate the effect of the strategy relative to conventional mobilisation.

RESULTS

Resected duodenal length was greater in Duo+ (median 3 vs 1cm; P<0.001); no distal-margin positivity in either group (0/90 vs 0/410). R0 rates were similar (95.6% vs 96.8%; P=0.78). Estimated blood loss did not differ (75 vs 55mL; P=0.18). Postoperative morbidity was numerically higher in Duo+ but not significant: Clavien-Dindo ≥II (40.0% vs 35.1%; P=0.38), ≥III (10.0% vs 7.1%; P=0.33), pancreatic fistula (5.6% vs 3.4%; P=0.42), duodenal stump fistula (2.2% vs 0.5%; P=0.17). Five-year overall survival was comparable (48% vs 52%; log-rank P=0.45).

CONCLUSIONS

In this single-centre retrospective series, an integrated extended-mobilisation and margin-control strategy was feasible during laparoscopic distal gastrectomy for gastric cancer with duodenal invasion, and no distal-margin-positive cases were observed among the Duo+ patients. These descriptive findings do not establish superiority or equivalence relative to conventional mobilisation or identify the contribution of any individual component of the strategy. Comparative multicentre studies are required.