Proximal gastrectomy offers shorter operative time but similar survival vs total gastrectomy in advanced gastric cancer

The optimal extent of gastrectomy for proximal advanced gastric cancer (PAGC) after neoadjuvant chemotherapy (NAC) remains controversial. While total gastrectomy (TG) has traditionally been considered oncological safer, proximal gastrectomy (PG) offers potential functional advantages. This meta-analysis aimed to compare short- and long-term outcomes between PG and TG after NAC. We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for studies comparing PG and TG in PAGC patients treated with NAC. Primary outcomes included overall survival (OS), recurrence-free survival (RFS), and postoperative complications. Supplementary TG-cohort data were extracted to assess distal lymph node metastasis patterns. Hazard ratios (HRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models as appropriate. Publication bias and result robustness were assessed through funnel plots, Galbraith plots, L’Abbé plots, and sensitivity analyses. Four propensity score-matched (PSM) comparative studies were included in the quantitative meta-analysis, comprising 284 patients undergoing PG and 305 patients undergoing TG after NAC. Baseline characteristics were comparable between groups. PG was associated with shorter operative time (MD −21.4 min, 95% CI −23.7 to −19.1) but slightly greater blood loss (MD 8.9 mL, 95% CI 4.9–12.8). Fewer lymph nodes were retrieved with PG (MD −3.9, 95% CI −4.5 to −3.3), but the number of metastatic nodes was similar (MD −0.27, 95% CI −0.63 to 0.09). Supplementary TG-cohort analysis showed low metastasis rates in distal lymph node stations (#4: 12.7%, #5: 4.8%, #6: 5.1%, and #12: 2.2%). Overall postoperative complications did not differ between PG and TG (OR 1.05, 95% CI 0.71–1.54), nor did Clavien-Dindo grade ≥ II complications (OR 1.08, 95% CI 0.69–1.71). No significant differences were observed in 5-year OS (HR 1.23, 95% CI 0.83–1.84) or RFS (HR 1.36, 95% CI 0.94–1.95). Sensitivity analyses supported the stability of the main pooled estimates. In patients with PAGC following NAC, PG provides comparable long-term oncological outcomes to TG without increasing postoperative morbidity or compromising adjuvant treatment delivery. PG represents a feasible oncological alternative to TG in appropriately selected patients. https://www.crd.york.ac.uk/prospero/, identifier CRD420261388093.