Evolution and future perspectives of the very small remnant stomach concept in minimally invasive gastrectomy

Preserving a very small proximal gastric remnant (SRS), often referred to as Laparoscopic Near-Total Gastrectomy (LNTG), is an emerging function-preserving strategy for upper-third gastric cancer. This systematic review and meta-analysis evaluates its evolution, clinical outcomes, and oncological safety.

Following PRISMA guidelines (PROSPERO: CRD420251062548), we systematically searched PubMed, Embase, MEDLINE, and SCI databases up to May 2025 for observational studies on LsTG with SRS. Methodological quality was assessed using the Newcastle-Ottawa Scale. Key short-term outcomes were quantitatively synthesized using a random-effects model.

Ten studies were included for qualitative review. Pooled analysis of non-overlapping cohorts revealed that LsTG with SRS was associated with significantly shorter operative time (Weighted Mean Difference [WMD] = -60.53 min), reduced intraoperative blood loss (WMD = -37.80 ml), and shorter postoperative hospital stay (WMD = -2.53 days) compared to conventional gastrectomies. Qualitative synthesis indicated favorable nutritional recovery and comparable short-term survival, largely attributed to fundus preservation.

LsTG with SRS is a safe, feasible procedure offering significant short-term surgical advantages and nutritional benefits. While promising, careful patient selection is paramount; current evidence supports this approach primarily for non-infiltrative, early-stage gastric cancers, while its use in diffuse-type or signet ring cell histology remains investigational and requires extreme caution. Future research must prioritize standardizing the SRS definition (e.g., 2-3 cm stump) and validating long-term oncological safety through prospective trials.