Size-dependent differences in the proximal remnant stomach: how much does a small remnant stomach after subtotal gastrectomy work?



The application of laparoscopic subtotal gastrectomy (LsTG) in the management of early gastric cancer located in the upper third of the stomach creates an extremely small remnant stomach (SRS). However, it is unclear whether retaining such an SRS improves patients’ postoperative outcomes in a similar manner to a conventional remnant stomach (CRS).


Four hundred and nine of 878 patients undergoing laparoscopic distal gastrectomy (LDG) between 2006 and 2012 underwent Roux-en-Y reconstruction. Among them, we selected 73 patients who underwent LsTG with an SRS (SRS group), and 83 patients with the tumor in the lower third of the stomach who underwent LDG with a CRS (CRS group). The surgical outcomes at 1 and 6 months, 1, 2, and 3 years after gastrectomy were retrospectively analyzed and compared between the two groups.


One year after gastrectomy, the postoperative:preoperative bodyweight ratio of the SRS group was 2% lower than that of the CRS group. Both groups had comparable total protein and albumin levels, and incidence of reflux esophagitis; however, hemoglobin was lower in the SRS group. This difference in hemoglobin level between the SRS and CRS groups became larger over time, although the total protein and albumin levels of the two groups remained similar.


An SRS slightly decreases bodyweight and hemoglobin level compared with a CRS. Several objective outcomes of the SRS group are almost equal to those of the CRS group, which suggests LsTG is worth performing even though its remnant stomach is very small.

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  1. 1.

    Okabayashi T, Gotoda T, Kondo H, Inui T, Ono H, Saito D, Yoshida S, Sasako M, Shimoda T (2000) Early carcinoma of the gastric cardia in Japan: is it different from that in the West? Cancer 89:2555–2559

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    An JY, Youn HG, Choi MG, Noh JH, Sohn TS, Kim S (2008) The difficult choice between total and proximal gastrectomy in proximal early gastric cancer. Am J Surg 196:587–591

    Article  PubMed  Google Scholar 

  3. 3.

    Lee SE, Ryu KW, Nam BH, Lee JH, Kim YW, Yu JS, Cho SJ, Lee JY, Kim CG, Choi IJ, Kook MC, Park SR, Kim MJ, Lee JS (2009) Technical feasibility and safety of laparoscopy-assisted total gastrectomy in gastric cancer: a comparative study with laparoscopy-assisted distal gastrectomy. J Surg Oncol 100:392–395

    Article  PubMed  Google Scholar 

  4. 4.

    Nunobe S, Hiki N, Tanimura S, Kubota T, Kumagai K, Sano T, Yamaguchi T (2011) Three-step esophagojejunal anastomosis with atraumatic anvil insertion technique after laparoscopic total gastrectomy. J Gastrointest Surg 15:1520–1525

    Article  PubMed  Google Scholar 

  5. 5.

    Jeong O, Ryu SY, Zhao XF, Jung MR, Kim KY, Park YK (2012) Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: experience at a large-volume center. Surg Endosc 26:3418–3425

    Article  PubMed  Google Scholar 

  6. 6.

    Hiki N (2013) Present features and future vision of laparoscopy-assisted total gastrectomy (LATG). Gastric Cancer 16:460–461

    Article  PubMed  Google Scholar 

  7. 7.

    Shim JH, Oh SI, Yoo HM, Jeon HM, Park CH, Song KY (2013) Short-term outcomes of laparoscopic versus open total gastrectomy: a matched-cohort study. Am J Surg 206:346–351

    Article  PubMed  Google Scholar 

  8. 8.

    Kitano S, Iso Y, Moriyama M, Sugimachi K (1994) Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 4:146–148

    CAS  PubMed  Google Scholar 

  9. 9.

    Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Recher A, Ponzano C (2005) Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 241:232–237

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Kitano S, Shiraishi N, Uyama I, Sugihara K, Tanigawa N (2007) A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 245:68–72

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, Bae JM (2008) Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg 248:721–727

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Tanimura S, Higashino M, Fukunaga Y, Takemura M, Tanaka Y, Fujiwara Y, Osugi H (2008) Laparoscopic gastrectomy for gastric cancer: experience with more than 600 cases. Surg Endosc 22:1161–1164

    CAS  Article  Google Scholar 

  13. 13.

    Katai H, Sasako M, Fukuda H, Nakamura K, Hiki N, Saka M, Yamaue H, Yoshikawa T, Kojima K (2010) Safety and feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG 0703). Gastric Cancer 13:238–244

    Article  Google Scholar 

  14. 14.

    Kim HH, Hyung WJ, Cho GS, Kim MC, Han SU, Kim W, Ryu SW, Lee HJ, Song KY (2010) Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report–a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg 251:417–420

    Article  PubMed  Google Scholar 

  15. 15.

    Lee SW, Nomura E, Bouras G, Tokuhara T, Tsunemi S, Tanigawa N (2010) Long-term oncologic outcomes from laparoscopic gastrectomy for gastric cancer: a single-center experience of 601 consecutive resections. J Am Coll Surg 211:33–40

    Article  PubMed  Google Scholar 

  16. 16.

    Fukunaga T, Hiki N, Kubota T, Nunobe S, Tokunaga M, Nohara K, Sano T, Yamaguchi T (2013) Oncologic outcomes of laparoscopy-assisted distal gastrectomy for gastric cancer. Ann Surg Oncol 20:2676–2682

    Article  PubMed  Google Scholar 

  17. 17.

    Jiang X, Hiki N, Nunobe S, Nohara K, Kumagai K, Sano T, Yamaguchi T (2011) Laparoscopy-assisted subtotal gastrectomy with very small remnant stomach: a novel surgical procedure for selected early gastric cancer in the upper stomach. Gastric Cancer 14:194–199

    Article  PubMed  Google Scholar 

  18. 18.

    Hiki N, Nunobe S, Kubota T, Jiang X (2013) Function-preserving gastrectomy for early gastric cancer. Ann Surg Oncol 20:2683–2692

    Article  PubMed  Google Scholar 

  19. 19.

    Kosuga T, Hiki N, Nunobe S, Noma H, Honda M, Tanimura S, Sano T, Yamaguchi T (2014) Feasibility and nutritional impact of laparoscopy-assisted subtotal gastrectomy for early gastric cancer in the upper stomach. Ann Surg Oncol 21:2028–2035

    Article  PubMed  Google Scholar 

  20. 20.

    Nomura E, Lee SW, Tokuhara T, Nitta T, Kawai M, Uchiyama K (2013) Functional outcomes according to the size of the gastric remnant and the type of reconstruction following distal gastrectomy for gastric cancer: an investigation including total gastrectomy. Jpn J Clin Oncol 43:1195–1202

    Article  PubMed  Google Scholar 

  21. 21.

    Japanese gastric cancer treatment guidelines (2010) ver. 3. Gastric Cancer 14:113–123

    Article  Google Scholar 

  22. 22.

    Japanese Gastric Cancer A (1998) Japanese classification of gastric carcinoma—2nd english edition. Gastric Cancer 1:10–24

    Article  Google Scholar 

  23. 23.

    Kawakatsu S, Ohashi M, Hiki N, Nunobe S, Nagino M, Sano T (2017) Use of endoscopy to determine the resection margin during laparoscopic gastrectomy for cancer. Br J Surg 104:1829–1836

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Nomura E, Lee SW, Bouras G, Tokuhara T, Hayashi M, Hiramatsu M, Okuda J, Tanigawa N (2011) Functional outcomes according to the size of the gastric remnant and type of reconstruction following laparoscopic distal gastrectomy for gastric cancer. Gastric Cancer 14:279–284

    Article  PubMed  Google Scholar 

  25. 25.

    Hirao M, Takiguchi S, Imamura H, Yamamoto K, Kurokawa Y, Fujita J, Kobayashi K, Kimura Y, Mori M, Doki Y (2013) Comparison of Billroth I and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: one-year postoperative effects assessed by a multi-institutional RCT. Ann Surg Oncol 20:1591–1597

    Article  PubMed  Google Scholar 

  26. 26.

    Inokuchi M, Kojima K, Yamada H, Kato K, Hayashi M, Motoyama K, Sugihara K (2013) Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy. Gastric Cancer 16:67–73

    Article  PubMed  Google Scholar 

  27. 27.

    Nakamura M, Nakamori M, Ojima T, Iwahashi M, Horiuchi T, Kobayashi Y, Yamade N, Shimada K, Oka M, Yamaue H (2016) Randomized clinical trial comparing long-term quality of life for Billroth I versus Roux-en-Y reconstruction after distal gastrectomy for gastric cancer. Br J Surg 103:337–347

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Annibale B, Capurso G, Delle Fave G (2003) The stomach and iron deficiency anaemia: a forgotten link. Dig Liver Dis 35:288–295

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Hiki N, Shimoyama S, Yamaguchi H, Kubota K, Kaminishi M (2006) Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation. J Am Coll Surg 203:162–169

    Article  PubMed  Google Scholar 

  30. 30.

    Jiang X, Hiki N, Nunobe S, Fukunaga T, Kumagai K, Nohara K, Katayama H, Ohyama S, Sano T, Yamaguchi T (2011) Long-term outcome and survival with laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc 25:1182–1186

    Article  PubMed  Google Scholar 

  31. 31.

    Jiang X, Hiki N, Nunobe S, Fukunaga T, Kumagai K, Nohara K, Sano T, Yamaguchi T (2011) Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Ann Surg 253:928–933

    Article  PubMed  Google Scholar 

  32. 32.

    Tsujiura M, Hiki N, Ohashi M, Nunobe S, Kumagai K, Ida S, Hayami M, Sano T, Yamaguchi T (2017) Excellent long-term prognosis and favorable postoperative nutritional status after laparoscopic pylorus-preserving gastrectomy. Ann Surg Oncol 24:2233–2240

    Article  PubMed  Google Scholar 

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Corresponding author

Correspondence to Manabu Ohashi.

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Itaru Yasufuku, Manabu Ohashi, Kojiro Eto, Satoshi Ida, Koshi Kumagai, Souya Nunobe, Takeshi Sano, and Naoki Hiki have no conflicts of interest or financial ties to disclose.

Ethical approval

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. As this study was a retrospective study and did not include any potentially identifiable patient data. The institutional review board gave the ethics approval for this retrospective study.

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Yasufuku, I., Ohashi, M., Eto, K. et al. Size-dependent differences in the proximal remnant stomach: how much does a small remnant stomach after subtotal gastrectomy work?. Surg Endosc 34, 5540–5549 (2020).

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  • Gastric cancer
  • Laparoscopic distal gastrectomy
  • Remnant stomach
  • Bodyweight
  • Hemoglobin