Current status, trends, and controversies in the selection of gastrectomy procedures: Insights from two nationwide questionnaire surveys conducted over a 7‐year interval in Japan

Abstract

Aim

This study explores the evolving landscape of gastrectomy procedures in Japan, based on nationwide surveys conducted in 2014 and 2021. It highlights changes in surgical approaches, including a growing focus on minimally invasive and function‐preserving procedures, as well as the increasing consideration of postoperative quality of life (QOL).

Methods

Two nationwide questionnaire surveys were conducted in 2014 and 2021, targeting members of the Japanese Society for Gastro‐surgical Pathophysiology. The surveys covered institutional characteristics, surgical case volumes, procedure preferences for early gastric cancer by tumor location, and emerging topics such as robot‐assisted surgery and sentinel node navigation surgery. Statistical analysis included Fisher's exact test and residual analysis for changes in procedure selection over time.

Results

The results indicate a marked shift toward laparoscopic and robot‐assisted gastrectomy, alongside a rise in function‐preserving procedures, particularly proximal gastrectomy and small remnant distal gastrectomy. However, procedures like pylorus‐preserving gastrectomy and vagus nerve preservation, and total gastrectomy with jejunal pouch reconstruction remain underutilized due to concerns regarding unclear benefits, technical complexity, and oncological safety.

Conclusion

This study underscores advancements in minimally invasive and function‐preserving gastrectomy procedures in Japan but emphasizes the need for more robust clinical evidence to support the broader adoption of certain procedures. Future research, guided by emerging evaluation tools, is crucial for optimizing surgical outcomes and enhancing QOL for gastric cancer patients.

This study investigates the evolving trends and challenges in gastrectomy procedures in Japan, drawing on two nationwide surveys conducted in 2014 and 2021. Results show a significant shift toward minimally invasive and function‐preserving surgeries, such as laparoscopic and robot‐assisted gastrectomy, with an emphasis on enhancing postoperative quality of life despite persistent concerns over technical complexity and oncological outcomes.

1. INTRODUCTION

Recent advancements in early detection and perioperative management have significantly improved the prognosis for gastric cancer patients. Laparoscopic gastrectomy has become the standard for minimally invasive surgery, while the growing adoption of robot‐assisted techniques has further enhanced surgical precision and safety. In addition to ensuring high curative rates, modern surgical approaches aim to minimize invasiveness and enhance long‐term survival. However, as long‐term survival rates improve, the enhancement of postoperative quality of life (QOL) has emerged as a pivotal aspect of patient‐centered care. To address this, several surgical procedures, including function‐preserving gastrectomies such as proximal gastrectomy, pylorus‐preserving gastrectomy (PPG), and vagus nerve‐preserving gastrectomy, as well as reconstructive methods such as total gastrectomy with jejunal pouch reconstruction (TGJP), have been developed with the aim of mitigating postoperative dysfunction and improving QOL.

Despite these advances, the details surrounding the actual selection of surgical procedures, reconstruction methods, and surgical technics used in Japan remain poorly understood. Additionally, temporal changes in surgical decision‐making and technique adoption have not been thoroughly explored. To fill this gap, we conducted two nationwide questionnaire surveys in conjunction with the 2014 and 2021 annual meetings of the Japanese Society for Gastro‐surgical Pathophysiology. The 2021 survey also included emerging topics in gastric surgery, such as the number of surgeries for adenocarcinoma of the esophagogastric junction (AEGJ) over the past decade, the introduction of robot‐assisted gastrectomy, and the implementation and significance of sentinel node navigation surgery.

2. METHODS

2.1. Questionnaire survey

Nationwide questionnaire surveys were conducted in conjunction with the 44th (2014) and 51st (2021) Annual Meetings of the Japanese Society for Gastro‐Surgical Pathophysiology. Structured questionnaires were sent via email to institutional members, aiming to capture temporal trends in gastrectomy procedure preferences, techniques, and emerging surgical topics.

The surveys covered the following key areas:

1. Institutional attributes—Classification of facilities as university hospitals, cancer centers, general hospitals, or other medical institutions.

2. Surgical case volume—Annual numbers of open and laparoscopic gastrectomies performed in the preceding year.

3. Gastrectomy procedure selection for early gastric cancer—Preferences for gastrectomy procedures based on tumor location (upper, middle, or lower stomach), including options such as total gastrectomy, proximal gastrectomy, PPG, and distal gastrectomy with either Billroth‐I or Roux‐en‐Y reconstruction. Respondents were also asked to provide reasons for selecting or avoiding specific procedures.

4. Reconstruction method selection—Reconstruction choices based on the size of the remnant stomach.

5. Surgical techniques—Specific surgical techniques used in total gastrectomy, proximal gastrectomy, PPG, and distal gastrectomy. Questions focused on the length and route of the Roux limb, the length of the antral cuff, techniques for each anastomosis, and methods for preventing reflux.

6. Vagus nerve preservation—Practices surrounding vagus nerve preservation in early gastric cancer surgeries, with emphasis on preserving the celiac and hepatic branches.

7. Impressions of function‐preserving gastrectomies—Surgeons' perceptions of various function‐preserving and reconstructive procedures, including proximal gastrectomy, small remnant distal gastrectomy (SRDG; where less than one‐fifth of the stomach remains, only in 2021), PPG, vagus nerve preservation, and TGJP.

The 2021 survey included additional topics, such as:

• 8Gastrectomy Procedure Selection in Cases Where Both Proximal Gastrectomy and SRDG Were Feasible.
• 9 Trends in AEGJ surgery—Data for annual number of operations spanning the previous decade (2011–2020).
• 10 Robot‐assisted gastrectomy—Questions on the introduction and use of robot‐assisted surgery, including adoption timing, cumulative case numbers, perceived benefits and limitations, and surgeon support.
• 11 Sentinel node navigation surgery—Experiences with sentinel node navigation surgery and support for its use in local resection of non‐endoscopic submucosal dissection (non‐ESD)‐eligible early gastric cancer cases (cT1N0M0, ≤4 cm).

The complete content of the questionnaire is presented in Table 1.

TABLE 1.

Translated survey questionnaire.

1. About your facility

Please indicate your facility type: 1: University hospital, 2: Cancer specialty facility, 3: General hospital, 4: Other (specify)

Number of open gastrectomies performed in the past year (or academic year) (N)

Number of laparoscopic gastrectomies performed in the past year (or academic year) (N)

2. Esophagogastric junction adenocarcinoma a

Number of surgeries for esophagogastric junction adenocarcinoma (EGJ) from 2011 to 2020 (or by academic year) (N): [Provide annual data]

3. Robot‐assisted gastrectomy a

Do you perform robot‐assisted gastrectomy? 1: Yes, 2: No

Year and month of introduction (yyyy/mm)

Number of procedures performed to date (N)

Number of procedures performed in the past year (or academic year) (N)

Advantages and disadvantages of robot‐assisted gastrectomy (list briefly)

Opinion on introducing robot‐assisted gastrectomy (select one): Strongly agree, Agree, Somewhat agree, Neutral, Somewhat disagree, Disagree, Strongly disagree, Uncertain

4. Sentinel node navigation gastrectomy a

Have you performed sentinel node navigation gastrectomy? 1: Yes, 2: No

Number of procedures performed to date (N)

Opinion on performing local resection of the stomach with this technique for non‐ESD‐eligible early gastric cancer (cT1N0M0, ≤4 cm; Assuming that insurance coverage) (select one): Strongly agree, Agree, Somewhat agree, Neutral, Somewhat disagree, Disagree, Strongly disagree, Uncertain

5A. Early gastric cancer in the upper stomach

(1) What is the primary procedure chosen?

1: Total gastrectomy, 2: Proximal gastrectomy, 3: Total gastrectomy + substitute stomach

Reasons for selecting or not selecting each of total gastrectomy, proximal gastrectomy, and total gastrectomy + substitute stomach

A‐1. About total gastrectomy

(1) Length of the Roux limb (cm)

(2) Preferred reconstruction route: 1: Antecolic, 2: Retrocolic

If Antecolic, is Petersen's defect closed? 1: Yes, 2: No

(3) Preferred method for esophagojejunostomy: 1: CS (circular stapled), 2: LS (linear stapled), 3: Hand‐sewn

(4) Preferred method for Y‐limb anastomosis: 1: CS (circular stapled), 2: LS (linear stapled), 3: Hand‐sewn

A‐2. About proximal gastrectomy

(1) Minimum remaining stomach size for performing proximal gastrectomy: 1: ≥2/3, 2: ≥1/2, 3: ≥1/3, 4: Do not perform

(2) Reconstruction method when 2/3 of the stomach remains: 1: Esophagogastrostomy, 2: Interposition, 3: Pouch Interposition, 4: Double Tract, 5: Other

(3) Reconstruction method when 1/2 of the stomach remains: 1: Esophagogastrostomy, 2: Jejunal Interposition, 3: Jejunal Pouch interposition, 4: Double tract, 5: Other

(4) Reconstruction method when 1/3 of the stomach remains: 1: Esophagogastrostomy, 2: Jejunal Interposition, 3: Jejunal Pouch interposition, 4: Double tract, 5: Other

(5) Do you perform proximal gastrectomy when the abdominal esophagus is resected? 1: Yes, 2: No

Reconstruction method following abdominal esophagus resection: 1. Esophagogastrostomy, 2. Jejunal Interposition, 3. Jejunal Pouch interposition, 4. Double tract, 5. Other

(6) Do you implement an anti‐reflux procedure during proximal gastrectomy? 1: Yes, 2: No

Anti‐reflux procedure for proximal gastrectomy: 1: Double‐flap, 2: His angle reconstruction and/or fundoplication, 3: mSOFY, 4: Original technique, 5: Other

(7) Preferred method for esophagogastrostomy: 1: CS (circular stapled), 2: LS (linear stapled), 3: Hand‐sewn

(8) Do you perform pyloric drainage for proximal gastrectomy? 1: Yes, 2: No

Procedure for pyloric drainage: 1: Pyloric bougie, 2: Pyloroplasty, 3: Other

A‐3. Total gastrectomy + substitute stomach

(1) Type of substitute stomach: 1: Jejunal pouch, 2: Ileocolonic interposition, 3: Other

(2) The length of jejunal pouch (cm)

(3) The site of jejunal pouch: 1: Pouch interposition, 2: Roux‐en‐Y oral pouch, 3: Roux‐en‐Y aboral pouch

A‐4. Small remnant distal gastrectomy a

(1) When both proximal gastrectomy and small remnant distal gastrectomy (with ≤1/5 of the stomach remaining) are feasible, which procedure do you prefer? 1: Proximal gastrectomy, 2: Small remnant distal gastrectomy

5B. Early gastric cancer in the middle stomach

(1) What is the primary procedure chosen? 1: Distal gastrectomy, 2: Pylorus‐preserving gastrectomy (PPG)

Reasons for selecting or not selecting each of distal gastrectomy and PPG

B‐1. About pylorus‐preserving gastrectomy (PPG)

(1) Minimum remaining stomach size for performing PPG: 1: ≥1/3, 2: ≥1/4, 3: Other

(2) Length of antral cuff (cm): 1: <3 cm, 2: 3–5 cm, 3: >5 cm

(3) Preferred length for antral cuff (cm)

(4) Method of gastrogastrostomy: 1: Hand‐sewn, 2: Stapled

(5) Preservation of right gastric artery? 1: Yes, 2: No

(6) Preservation of infrapyloric artery? 1: Yes, 2: No

5C. Early gastric cancer in the lower stomach

(1) Primary method of reconstruction: 1: Billroth‐I, 2: Roux‐en‐Y

Reasons for selecting or not selecting each of Billroth‐I and Roux‐en‐Y reconstruction

(2) Reconstruction method when 1/2 of the stomach remains: 1: Billroth‐I, 2: Roux‐en‐Y, 3: Other

(3) Reconstruction method when 1/3 of the stomach remains: 1: Billroth‐I, 2: Roux‐en‐Y, 3: Other

(4) Reconstruction method when 1/4 of the stomach remains: 1: Billroth‐I, 2: Roux‐en‐Y, 3: Other

C‐1. Anastomosis in Billroth‐I reconstruction a

(1) Preferred method of anastomosis: 1: Delta, 2: CS, 3: Other

(2) Method of gastroduodenostomy: 1: CS, 2: LS, 3: Hand‐sewn

C‐2. Anastomosis in Roux‐en‐Y reconstruction

(1) Preferred reconstruction route: 1: Antecolic, 2: Retrocolic

If Antecolic, is Petersen's defect closed? 1: Yes, 2: No

(2) Length of the Roux limb (cm)

5D. Vagus nerve preservation

(1) Is the vagal celiac branch preservation performed for early gastric cancer? 1: Yes, 2: No

Reasons for preserving or not preserving the vagal celiac branch

(2) In which surgical procedure is the vagal celiac branch preserved? 1: TG, 2: PG, 3: TGJP, 4: PPG, 5: DG

(1) Is the vagal hepatic branch preservation performed for early gastric cancer? 1: Yes, 2: No

Reasons for preserving or not preserving the vagal hepatic branch

(2) In which surgical procedure is the vagal hepatic branch preserved? 1: TG, 2: PG, 3: TGJP, 4: PPG, 5: DG

5E. Function‐preserving and function‐reconstructing surgery

(1) Do you believe proximal gastrectomy mitigates postgastrectomy syndrome?

(2) Do you believe substitute stomach (jejunal pouch) mitigates postgastrectomy syndrome?

(3) Do you believe small remnant distal gastrectomy mitigates postgastrectomy syndrome? a

(4) Do you believe PPG mitigates postgastrectomy syndrome?

(5) Do you believe vagal celiac branch preservation mitigates postgastrectomy syndrome?

(6) Do you believe that the improvement and wider adoption of superior gastrectomy procedures mitigate postgastrectomy syndrome?

Response scale for (1)–(6)

1 = Strongly agree, 2 = Agree, 3 = Somewhat agree, 4 = Neutral, 5 = Disagree

5F. Long‐term outcomes of total gastrectomy + jejunal pouch reconstruction

(1) Number of total gastrectomies with jejunal pouch performed to date (N)

(2) Complications related to jejunal pouch (number of cases for each): 1: Pouch dilatation, 2: Evacuation disorder, 3: Others a

(3) Potential causes of pouch‐related complications: 1: Oversized jejunal pouch, 2: Bending, adhesion, or torsion of the efferent jejunal limb, 3: Others b

^a Investigated solely in the 2021 survey.

^b Investigated solely in the 2014 survey.

2.2. Statistical analysis

Temporal differences in gastrectomy procedure preferences were evaluated using Fisher's exact test, with residual analysis performed for multi‐group comparisons when p‐values were below 0.05. A two‐sided p‐value of less than 0.05 was considered statistically significant. Statistical analyses were conducted using Fisher's Test for Exact Count Data and JMP 12.0.1 (SAS Institute Inc.).

3. RESULTS

3.1. Institutional attributes, surgical case volume, and surgical approaches (Table 2)

TABLE 2.

Attributes of respondent institutions, number of gastrectomy cases and surgical approaches for gastrectomy.

	Questionnaire survey in 2014		Questionnaire survey in 2021		Fisher's exact test
	N	%	N	%	p‐Value
Number of responding institutions	117		148		0.347
University hospital	62	53.0	77	52.0
Specialized cancer institution	17	14.5	14	9.5
General hospital	38	32.5	57	38.5
Total number of gastrectomy cases in the past year	12 480		10 255		<0.001
Open surgery	7278	58.3	3275	31.9
Laparoscopic (assisted) surgery	5202	41.7	6980	68.1
Number of gastrectomy cases in the past year at each institution
Less than 20 cases	3	2.6	13	9.0	<0.001
Less than 50 cases	16	13.9	40	27.6
Less than 100 cases	43	37.4	69	47.6
Less than 200 cases	45*	39.1	18**	12.4
More than 200 cases	8	7.0	5	3.4
Percentage of laparoscopic gastrectomy at each institution
Less than 25%	24*	20.9	7**	4.9	<0.001
Less than 50%	49	42.6	36	25.0
Less than 75%	36	31.3	47	32.6
More than 75%	6**	5.2	54*	37.5

*Significantly more, **significantly less (p < 0.05; residual analysis).

In 2014, responses were received from 117 of 210 institutions (56%), while 148 of 199 institutions (74%) participated in 2021. The institutional distribution remained consistent, with university hospitals accounting for approximately half of the respondents in both years (53.0% in 2014 and 52.0% in 2021). Cancer centers represented 14.5% in 2014 and 9.5% in 2021, while general hospitals comprised 32.5% and 38.5%, respectively. The total number of gastrectomies performed in the preceding year declined from 12 480 cases across 117 institutions in 2014 to 10 255 cases across 148 institutions in 2021, with a significant decrease in average annual gastrectomy volume per institution, from 106.7 in 2014 to 69.3 in 2021. Notably, the proportion of institutions performing 100–199 gastrectomies annually dropped from 39.1% in 2014 to 12.4% in 2021 (p < 0.05).

Laparoscopic procedures increased significantly, accounting for 41.7% of cases in 2014 and 68.1% in 2021 (p < 0.001). Institutions where laparoscopic surgeries constituted 75% or more of total procedures rose from 5.2% in 2014 to 37.5% in 2021 (p < 0.05), while those with 25% or fewer laparoscopic procedures decreased from 20.9% in 2014 to 4.9% in 2021 (p < 0.05).

3.2. Preferred gastrectomy procedures for early gastric cancer by tumor location (Table 3)

TABLE 3.

Primary gastrectomy procedures for early gastric cancer by tumor location in the upper, middle, and lower stomach.

	Questionnaire survey in 2014		Questionnaire survey in 2021		Fisher's exact test
	N	%	N	%	p‐Value
Upper stomach early gastric cancer
Total gastrectomy	31*	26.5	6**	4.1	<0.001
Proximal gastrectomy	84	71.8	139	95.9
Total gastrectomy with jejunal pouch creation	2	1.7	0	0.0
Distal residual stomach size to perform proximal gastrectomy
2/3 or more	35	39.3	34	23.8	0.016
1/2 or more	54	60.7	106	74.1
1/3 or more	0	0.0	3	2.1
When the abdominal esophagus is resected
Perform proximal gastrectomy	49	62.8	132	90.4	<0.001
Do not perform proximal gastrectomy	29	37.2	14	9.6
When both proximal gastrectomy and SRDG are possible
Perform proximal gastrectomy	NA		46	31.5
Perform SRDG	NA		100	68.5
Middle stomach early gastric cancer
Distal gastrectomy	77	67.0	116	78.9	0.034
PPG	38	33.0	31	21.1
Proximal residual stomach size to perform PPG
1/3 or more	35	72.9	45	88.2	0.154
1/4 or more	3	6.3	2	3.9
Others	10	20.8	4	7.8
Lower stomach early gastric cancer
Distal gastrectomy with Billroth‐I method	96	82.1	121	81.8	1.000
Distal gastrectomy with Roux‐en‐Y method	17	14.5	21	14.2
Others	4	3.4	6	4.1

Abbreviations: PPG, pylorus preserving gastrectomy; SRDG, small remnant distal gastrectomy.

*Significantly more, **significantly less (p < 0.05; residual analysis).

For early upper gastric cancer, proximal gastrectomy was the preferred approach, increasing from 71.8% in 2014 to 95.9% in 2021 (p < 0.001). Conversely, the use of total gastrectomy decreased (p < 0.05), with total gastrectomy combined with jejunal pouch reconstruction remaining rare in both years. The proportion of cases favoring proximal gastrectomy when at least half of the stomach remained rose from 60.7% in 2014 to 74.1% in 2021 (p = 0.016). Additionally, the rate of proximal gastrectomy with abdominal esophageal resection increased significantly from 62.8% in 2014 to 90.4% in 2021 (p < 0.001). In cases where both proximal gastrectomy and SRDG were feasible, SRDG was selected by 68.5%, while proximal gastrectomy was chosen by 31.5% in 2021.

For middle early gastric cancer, distal gastrectomy remained the preferred choice, with utilization increasing from 67.0% in 2014 to 78.9% in 2021 (p = 0.034).

For lower early gastric cancer, distal gastrectomy with Billroth‐I reconstruction remained the most frequently selected procedure in both surveys, performed by 82.1% in 2014 and 81.8% in 2021, with no significant changes observed in the preference for Billroth‐I over Roux‐en‐Y reconstruction.

3.3. Selection of reconstruction methods by remnant stomach size (Table 4)

TABLE 4.

Primary reconstruction methods for each gastrectomy procedure.

	Questionnaire survey in 2014		Questionnaire survey in 2021		Fisher's exact test
	N	%	N	%	p‐Value
Proximal gastrectomy
When the distal residual stomach size is approximately 2/3
Esophagogastrostomy	58	71.6	119	83.2	0.001
Double tract	11	13.6	21	14.7
Jejunal interposition	9*	11.1	2	1.4
Jejunal pouch interposition	0	0.0	1	0.7
Others	3	3.7	0	0.0
When the distal residual stomach size is approximately 1/2
Esophagogastrostomy	13	21.3	41	33.1	<0.001
Double tract	23	36.1	78	64.5
Jejunal interposition	16*	26.2	3**	2.4
Jejunal pouch interposition	4	6.6	1	0.0
Others	3*	9.8	0	0.0
When the abdominal esophagus is resected
Esophagogastrostomy	13	24.1	53	40.8	<0.001
Double tract	20	37.0	73	56.2
Jejunal interposition	17*	31.5	3**	2.3
Jejunal pouch interposition	1	1.9	1	0.8
Others	3*	5.6	0	0.0
Distal gastrectomy
When the proximal residual stomach size is approximately 1/2
Billroth‐I method	100	86.2	131	90.3	0.164
Roux‐en‐Y method	11	9.5	13	9.0
Others	5	4.3	1	0.7
When the proximal residual stomach size is approximately 1/3
Billroth‐I method	78	67.8	93	62.8	0.725
Roux‐en‐Y method	31	27.0	46	31.1
Others	6	5.2	9	6.1
When the proximal residual stomach size is approximately 1/4
Billroth‐I method	8	7.0	4	2.7	0.235
Roux‐en‐Y method	100	87.7	137	93.2
Others	6	5.3	6	4.1

*Significantly more, **significantly less (p < 0.05; residual analysis).

The choice of reconstruction methods following both proximal and distal gastrectomy varied according to the size of the remaining stomach. For proximal gastrectomy, esophagogastrostomy was the most common reconstruction technique when approximately two‐thirds of the stomach remained, selected by 71.6% in 2014 and 83.2% in 2021. When the remnant stomach was reduced to approximately half its original size, double‐tract reconstruction was preferred, with usage increasing from 36.1% in 2014 to 64.5% in 2021. In cases involving resection of the abdominal esophagus, double‐tract reconstruction also remained the predominant choice, with a significant increase from 37.0% in 2014 to 56.2% in 2021. Conversely, jejunal interposition reconstruction following proximal gastrectomy was the second most commonly performed reconstruction method overall in 2014, following double tract reconstruction. Specifically, it was used by 16 institutions (26.2%) for smaller gastric remnants, approximately half the original stomach size, and by 17 institutions (31.5%) when the abdominal esophagus was resected. However, by 2021, this method had significantly declined, being performed by only three institutions in each case.

For distal gastrectomy, Billroth‐I reconstruction was typically employed, while Roux‐en‐Y reconstruction was favored in cases with a smaller remnant stomach, particularly when the remaining portion was approximately one‐quarter of the original size.

3.4. Surgical techniques for each procedure (Table 5)

TABLE 5.

Primary surgical techniques for each type of gastrectomy.

	Questionnaire survey in 2014		Questionnaire survey in 2021		Fisher's 3 exact test
	N	%	N	%	p‐Value
Total gastrectomy
Elevation route for Roux limb
Antecolic	35	55.6	105	71.4	0.037
Retrocolic	28	44.4	42	28.6
Anastomotic technique for esophagojejunostomy
Circular stapled	52*	85.2	48**	33.1	<0.001
Linear stapled	9**	14.8	96*	66.2
Handsewn	0	0.0	1	0.7
Anastomotic technique for Y limb
Circular stapled	10	16.4	10	6.9	<0.001
Linear stapled	16**	26.2	91	63.2
Handsewn	35*	57.4	43	29.9
The length of Roux limb
20 cm	1	1.6	0	0.0
30 cm	4	6.3	6	4.1
35 cm	3	4.8	7	4.8
40 cm	331st	52.4	891st	61.0
45 cm	152nd	23.8	352nd	24.0
50 cm	5	7.9	9	6.2
55 cm	1	1.6	0	0.0
60 cm	1	1.6	0	0.0
Proximal gastrectomy
Anti‐reflux procedure for esophagogastrostomy method
Perform anti‐reflux procedure	47	57.3	118	81.9	<0.001
Do not perform anti‐reflux procedure	35	42.7	26	18.1
Type of anti‐reflux procedure
His angle formation and/or fundoplication	22*	48.9	23	19.5	<0.001
Pseudo‐fornix creation	12*	26.7	4**	3.4
Double‐flap technique	9	20.0	33	28.0
(m)SOFY method	0**	0.0	47*	39.8
Others	2	4.4	11	9.3
Anastomotic technique for esophagogastrostomy
Circular stapled	NA		20	14.9
Linear stapled	NA		78	58.2
Handsewn	NA		36	26.9
Pyloric drainage procedure for proximal gastrectomy
Perform pyloric drainage procedure	14	16.3	14	9.9	0.211
Do not perform pyloric drainage procedure	72	83.7	128	90.1
Type of pyloric drainage procedure
Pyloric bougie	13	92.9	12	92.3	1.000
Pyloroplasty	1	7.1	1	7.7
PPG
Anastomotic technique for gastrogastrostomy
Linear stapled	13	26.0	23	44.2	0.064
Handsewn	37	74.0	29	55.8
The length of antral cuff
Shorter than 3 cm	1	2.0	1	1.9	0.689
Between 3 and 5 cm	41	82.0	46	88.5
Longer than 5 cm	8	16.0	5	9.6
The length of antral cuff considered most appropriate
2.5 cm	0	0.0	1	2.0
3.0 cm	6	13.3	11	21.6
3.5 cm	2	4.4	0	0.0
4.0 cm	251st	55.6	251st	49.0
5.0 cm	102nd	22.2	122nd	23.5
6.0 cm	2	4.4	2	3.9
Distal gastrectomy
Billroth‐I method
Anastomotic technique for gastroduodenostomy
Circular stapled	NA		9	6.5
Linear stapled	NA		126	90.6
Handsewn	NA		4	2.9
Type of gastroduodenostomy procedure
Delta‐shaped anastomosis	NA		108	77.7
Circular stapled	NA		11	7.9
Triangle‐shaped anastomosis	NA		8	5.8
Others	NA		12	8.6
Roux‐en‐Y method
Elevation route for Roux limb
Antecolic	73	65.2	119	80.4	0.007
Retrocolic	39	34.8	29	19.6
The length of Roux limb
15 cm	2	1.8	0	0.0
20 cm	11	9.8	13	8.8
25 cm	14	12.5	12	8.2
30 cm	461st	41.1	581st	39.5
35 cm	11	9.8	25	17.0
40 cm	262nd	23.2	352nd	23.8
45 cm	1	0.9	2	1.4
50 cm	1	0.9	1	0.7
60 cm	0	0.0	1	0.7
Preservation of the vagus nerve for early gastric cancer
The celiac branch of the vagus nerve
Preserve	32	27.4	14	9.6	<0.001
Not preserve	85	72.6	132	90.4
The hepatic branch of the vagus nerve
Preserve	89	78.1	113	78.5	1.000
Not preserve	25	21.9	31	21.5

Note: The superscript ‘1st’ and ‘2nd’ indicate the rankings based on the number of institutions.

Abbreviation: (m)SOFY, (modified) side overlap with fundoplication by Yamashita.

*Significantly more, **significantly less (p < 0.05; residual analysis).

For total gastrectomy, the use of the antecolic route for Roux limb elevation increased from 55.6% in 2014 to 71.4% in 2021 (p = 0.037). While circular‐stapled esophagojejunostomy was the predominant method in 2014 (85.2%), there was a notable shift toward linear‐stapled anastomosis by 2021, chosen by 66.2% (p < 0.001).

For proximal gastrectomy with esophagogastrostomy, anti‐reflux procedures became more common, rising from 57.3% in 2014 to 81.9% in 2021 (p < 0.001). Modified side overlap fundoplication by Yamashita (mSOFY) and the double‐flap technique became increasingly popular, gradually replacing earlier methods like His angle reconstruction and fundoplication.

Hand‐sewn gastrogastrostomy was initially the dominant technique for PPG in 2014 (74.0%), but its use declined to 55.8% in 2021, with a corresponding rise in linear‐stapled anastomosis from 26.0% to 44.2% (p = 0.064). The preferred antral cuff length remained at 3–5 cm in both years, with 4.0 cm being the most commonly selected.

For distal gastrectomy with Billroth‐I reconstruction, linear‐stapled gastroduodenostomy was the most commonly used method by 2021 (90.6%). Among the anastomotic techniques, the delta‐shaped method was most preferred.

Vagus nerve preservation was practiced less frequently in 2021 compared to 2014, particularly regarding the celiac branch, which decreased significantly from 27.4% in 2014 to 9.6% in 2021 (p < 0.001). However, preservation of the hepatic branch remained more common, with 78.1% in 2014 and 78.5% in 2021, showing no significant change over time.

3.5. Surgeons' perceptions of gastrectomy procedures in mitigating postgastrectomy syndrome (Table 6)

TABLE 6.

Surgeons' perceptions of gastrectomy procedures in mitigating postgastrectomy syndrome.

	Questionnaire survey in 2014		Questionnaire survey in 2021		Fisher's exact test
	N	%	N	%	p‐Value
Improvement and wider adoption of superior gastrectomy procedures
Strongly agree	59	50.4	90	61.2	0.265
Agree	41	35.0	45	30.6
Somewhat agree	11	9.4	9	6.1
Neither agree nor disagree	5	4.3	2	1.4
Rather disagree	1	0.9	1	0.7
Performing proximal gastrectomy
Strongly agree	8**	6.8	30*	20.8	<0.001
Agree	36	30.8	52	36.1
Somewhat agree	41	35.0	53	36.8
Neither agree nor disagree	29*	24.8	8**	5.6
Rather disagree	3	2.6	1	0.7
Performing small remnant distal gastrectomy
Strongly agree	NA		27	18.4
Agree	NA		55	37.4
Somewhat agree	NA		41	27.9
Neither agree nor disagree	NA		21	14.3
Rather disagree	NA		3	2.0
Performing PPG
Strongly agree	10	8.7	4	2.8	0.048
Agree	26	22.6	26	18.2
Somewhat agree	40	34.8	42	29.4
Neither agree nor disagree	34	29.6	65	45.5
Rather disagree	5	4.3	6	4.2
Performing vagal celiac branch preservation
Strongly agree	3	2.6	1	0.7	0.354
Agree	14	12.0	11	7.5
Somewhat agree	28	23.9	34	23.3
Neither agree nor disagree	72	61.5	100	68.5
Rather disagree	0	0.0	0	0.0
Performing total gastrectomy with jejunal pouch reconstruction
Strongly agree	7	6.2	3	2.1	0.355
Agree	1	0.9	5	3.5
Somewhat agree	9	8.0	12	8.3
Neither agree nor disagree	66	58.4	83	57.6
Rather disagree	30	26.5	41	28.5

*Significantly more, **significantly less (p < 0.05; residual analysis).

The majority of surveyed surgeons emphasized the importance of refining gastrectomy procedures to mitigate postgastrectomy syndromes. In 2014, 94.9% supported this perspective, increasing to 98.0% in 2021, indicating a broad consensus on the necessity of procedural innovation. Proximal gastrectomy was particularly regarded as effective, with support rising from 72.6% in 2014 to 93.8% in 2021. Similarly, SRDG was favored by 83.7% in 2021. Conversely, support for PPG declined from 66.1% in 2014 to 50.3% in 2021 (p = 0.048). Vagus nerve preservation, particularly the celiac branch, also saw a decline in support, with 38.5% in favor in 2014, dropping to 31.5% in 2021. Surgeons generally viewed TGJP as less effective in mitigating postgastrectomy syndromes, with support remaining low across both surveys (15.0% in 2014 and 13.9% in 2021).

3.6. Reasons for performing or not performing specific procedures (Table 7)

TABLE 7.

Main reasons for performing or not performing concerned gastrectomy procedure.

	Reasons for performing a	Reasons for not performing a
Proximal gastrectomy	Better QOL (43)	High incidence of reflux esophagitis (10)
	Preservation of stomach (43)	Complicated surgical procedure (5)
	Preservation of function (36)
	Greater food intake (25)
	Less weight loss (23)
Small remnant distal gastrectomy	Preservation of anti‐reflux function (16)	Concerns about curative of cancer (10)
	Greater food intake (16)	Preservation of stomach (5)
	Better QOL (10)
	Safety (9)
	Less esophageal reflux (8)
	Preservation of ghrelin secretion (8)
	Easy to reconstruct (8)
PPG	Preservation of function (21)	Delayed gastric emptying (53)
	Less dumping symptoms (17)	Concerns about curative of cancer (34)
	Better QOL (16)	Unclear advantages (33)
	Less weight loss (8)	Complicated surgical procedure (25)
	No concern about curative of cancer (5)	No experience (12)
Preservation of the celiac branch of the vagus nerve	Preservation of function (16)	Unclear advantages (110)
	Less diarrhea symptoms (11)	Concerns about curative of cancer (48)
		Complicated surgical procedure (30)
		No experience (5)
Total gastrectomy with jejunal pouch reconstruction	NA	Unclear advantages (58)
		Complicated surgical procedure (48)
		No experience (25)
		Delayed gastric emptying (7)
		Poor QOL (7)

Note: Integrated the responses for questionnaire survey in 2014 and in 2021.

^a Maximum of 5 items with the number of responses was more than 5.

When asked why they performed function‐preserving or function‐reconstructing gastrectomies, to sum up the whole thing, surgeons most commonly cited the preservation of gastric function as the primary motivation (73 institutions), followed by better postoperative QOL (69 institutions), increased food intake (41 institutions), reduced symptoms of postgastrectomy syndrome (36 institutions), and minimized weight loss (31 institutions). Conversely, the reasons cited for not performing these procedures were, to sum up the whole thing, primarily the perceived lack of clear benefits (201 institutions), followed by the complexity of the techniques (108 institutions), concerns about oncological radicality (92 institutions), the risk of procedure‐specific complications (70 institutions), and limited surgical experience with the techniques (42 institutions). These findings highlight the need for stronger clinical evidence and improved training to address concerns and encourage wider adoption of these procedures.

3.7. Topics related to gastric surgery (Table 8)

TABLE 8.

Topics surrounding gastric cancer surgery.

	Questionnaire survey in 2014		Questionnaire survey in 2021
	N	%	N	%
Esophagogastric junction adenocarcinoma
Number of gastrectomy cases (135 institutions with no missing data)
Year 2011			552
Year 2012			573
Year 2013			538
Year 2014			549
Year 2015			586
Year 2016			667
Year 2017			706
Year 2018			743
Year 2019			732
Year 2020			725
Robotic gastrectomy
Perform robotic gastrectomy			81	55.5
Do not perform robotic gastrectomy			65	44.5
Introduction period of robotic gastrectomy
Year 2011			3
Year 2012			3
Year 2013			3
Year 2014			5
Year 2015			6
Year 2016			3
Year 2017			16
Year 2018			14
Year 2019			14
Year 2020			9
Year 2021 (until Sep.)			4
Surgeon's opinion on performing robotic gastrectomy
Strongly agree			37	28.9
Agree			51	39.8
Slightly agree			22	17.2
Neither agree nor disagree			17	13.3
Slightly disagree			0	0.0
Disagree			1	0.8
Strongly disagree			0	0.0
Not sure			0	0.0
Sentinel node navigation surgery for early gastric cancer
Experience in enforcing sentinel node navigation surgery
Experienced in enforcement			28	19.0
No experience in enforcement			119	81.0
Surgeon's opinion on performing local resection with SNNS for non‐ESD‐eligible EGC (cT1N0M0, ≤4 cm)
Strongly agree			6	4.6
Agree			30	22.9
Slightly agree			25	19.1
Neither agree nor disagree			49	37.4
Slightly disagree			9	6.9
Disagree			6	4.6
Strongly disagree			0	0.0
Not sure			6	4.6
Total gastrectomy with jejunal pouch reconstruction
Cumulative number of cases	1375		1156
Number of Jejunal pouch related complication cases	53	3.9	41	3.5
Consideration of the causes of pouch‐related complications
Jejunal pouch too large	26		NA
Kinking, twisting or adhesion of efferent loop	13		NA
Others	4		NA
Type of Jejunal pouch related complication
Abnormal dilation of jejunal pouch	NA		29
Impaired emptying	NA		9
Others	NA		3

Abbreviations: EGC, early gastric cancer; ESD, endoscopic submucosal dissection; SNNS, sentinel node navigation surgery.

The number of surgeries performed for AEGJ increased steadily over the past decade (2011–2020), in line with global trends reflecting a rise in this cancer subtype.

In 2021, 56% of institutions had introduced robot‐assisted gastrectomy, with most adopting this technology following its approval for insurance coverage in Japan in April 2018. The majority of institutions introduced robotic surgery between 2017 and 2021. The adoption rates of robot‐assisted gastrectomy, stratified by facility classification, were highest among specialized cancer centers (92.9%, 13 institutions), followed by university hospitals (68.8%, 53 institutions), and general hospitals (28.6%). Surgeons cited the primary advantages of robot‐assisted surgery as multi‐jointed instruments (35 institutions), tremor reduction (22 institutions), and improved precision (20 institutions). However, major drawbacks were noted, including high costs (51 institutions), prolonged operative times (35 institutions), and the lack of tactile feedback (17 institutions). Despite these challenges, support for robot‐assisted gastrectomy was high, with 128 institutions (86%) expressing approval of its implementation.

With regard to sentinel node navigation surgery, among the respondents, only 19% had experience with this procedure, underscoring its limited adoption in clinical practice. Potential barriers to its widespread implementation include concerns regarding oncological safety, the technical complexity of the procedure, and its current designation as advanced medical care, which is not covered by insurance (unpublished data). When asked about performing local resection combined with sentinel node navigation surgery for non‐ESD‐eligible early gastric cancer (cT1N0M0, ≤4 cm), 47% supported its application, while 11% were opposed. These findings suggest that sentinel node navigation surgery could be a potential option for treating early‐stage gastric cancer, especially in cases where ESD is not feasible.

The cumulative number of TGJP was 1375 cases in 2014 and 1156 cases in 2021. Despite the surgeon's concerns, the incidence of pouch‐related complications remained low in both years, with 53 cases (3.9%) in 2014 and 41 cases (3.5%) in 2021. The most common complications were pouch dilation (29 cases, 71%) and pouch outlet obstruction (nine cases, 22%). The estimated primary causes of these complications were oversized pouches (26 cases, 49%) and twisted or adhesed efferent jejunal limbs (13 cases, 25%), which resulted in obstructed pouch emptying.

4. DISCUSSION

Over the 7‐year period from 2014 to 2021, significant shifts were observed in the selection of gastrectomy procedures and surgical approaches in Japan. The trend toward minimally invasive procedures, particularly laparoscopic gastrectomy, became more prominent, while the adoption of robot‐assisted gastrectomy continued to increase. Proximal gastrectomy for upper gastric cancer, as well as SRDG, gained traction, reflecting a growing emphasis on postoperative QOL for patients undergoing gastric cancer surgery. Although function‐preserving and function‐reconstructing gastrectomy procedures have gained recognition, the evidence supporting their efficacy in mitigating postgastrectomy syndromes remains insufficient. Procedures such as PPG, vagus nerve preservation, and TGJP continue to face challenges in terms of adoption. The primary concerns raised by surgeons include unclear benefits, technical complexity, oncological radicality, and potential complications.

Laparoscopic gastrectomy has established itself as the standard treatment for early gastric cancer, given its reduced invasiveness, faster recovery times, and lower complication rates compared to open surgery. ¹ Since its introduction in Japan in 1994, ² laparoscopic techniques have been steadily adopted. The approval of robot‐assisted gastrectomy for insurance coverage in 2018 further accelerated the shift toward minimally invasive surgery, enhancing precision and safety. Our findings indicate a significant increase in laparoscopic gastrectomies from 2014 to 2021, accompanied by a decline in open procedures. The widespread adoption of robot‐assisted techniques underscores the ongoing emphasis on minimally invasive approaches, contributing to improved surgical outcomes and patient safety.

Proximal gastrectomy is recommended by the Japanese Gastric Cancer Treatment Guidelines (ver. 6; 2021) ³ for early‐stage upper gastric cancer due to its superior postoperative outcomes compared with total gastrectomy, including mitigated incidences of postgastrectomy syndromes, such as diarrhea and dumping syndrome, as well as better preservation of body weight and food intake. ⁴ This study confirms a significant increase in the use of proximal gastrectomy over time (p < 0.001), with reconstruction methods tailored to the size of the remnant stomach. Esophagogastrostomy was preferred for larger remnants, while double‐tract reconstruction was favored when the remnant was smaller or when the abdominal esophagus was resected. Each reconstruction method has distinct advantages and challenges. Esophagogastrostomy, although technically simpler, carries risks of postoperative reflux esophagitis and anastomotic stricture. ⁵ Anti‐reflux techniques, such as His angle reconstruction, fundoplication, and the double‐flap technique, have been employed to address these complications. Our survey identified a significant shift in preferred anti‐reflux techniques over time, with newer methods, such as mSOFY ⁶ and the double‐flap technique, ⁷ gaining popularity in recent years. Recent reports indicate no significant differences in postoperative QOL among the various anastomosis techniques, ⁸ underscoring the need for further refinement and validation. While double‐tract reconstruction involves three anastomosis sites, each technique has been standardized, making the procedure technically straightforward. However, there are concerns that food may primarily transit through the jejunum without adequately reaching the remnant stomach, potentially causing nutritional challenges similar to total gastrectomy. To address this issue, optimizing jejunogastrostomy procedures to enhance food flow into the remnant stomach is essential, and various modifications have been implemented toward this goal. ⁹ , ¹⁰ Studies comparing esophagogastrostomy with double‐tract reconstruction in proximal gastrectomy have generally shown superior postoperative QOL with the latter. ¹¹ , ¹² Nonetheless, ongoing improvements are being made to both methods, making definitive conclusions premature. A comparative evaluation of both techniques' impact on postoperative QOL should be revisited once these issues are addressed.

SRDG has also demonstrated favorable QOL outcomes and may be preferable to proximal gastrectomy, given its association with fewer symptoms, greater food intake, and less weight loss. ¹³ In this study, SRDG was chosen in about 70% of cases where both procedures were feasible, reflecting its recognized QOL benefits.

PPG is a function‐preserving procedure for early middle gastric cancer and is recommended by the Japanese Gastric Cancer Treatment Guidelines (ver. 6; 2021) ³ due to its superior postoperative outcomes compared with distal gastrectomy. Its advantages over distal gastrectomy include a reduced incidence of diarrhea and dumping syndrome, better food intake, and less weight loss. ¹⁴ However, postoperative gastric stasis—a complication specific to PPG—has raised concerns among surgeons, as it can delay recovery and complicate postoperative care. ¹⁵ In our survey, distal gastrectomy remained the preferred choice for early middle gastric cancer, while PPG use significantly declined over time. The reduced adoption of PPG may be attributed to concerns about postoperative gastric stasis, uncertainties regarding its oncological adequacy, ambiguous benefits, and the complexity of the procedure (Table 7).

Distal gastrectomy, particularly with Billroth‐I reconstruction, remains the most frequently selected procedure for early lower gastric cancer. Our survey found no significant change in its popularity over time. When the remnant stomach was smaller (approximately one‐quarter of the stomach), Roux‐en‐Y reconstruction was more commonly selected, as Billroth‐I reconstruction in such cases has been associated with higher rates of postoperative reflux esophagitis and reflux gastritis. ¹⁶ Conversely, when the remnant stomach was larger, Roux‐en‐Y reconstruction was associated with a higher incidence of gastric stasis, ¹⁷ a complication that can affect postoperative recovery and nutrition. These findings support that current practices in selecting reconstruction methods following distal gastrectomy seem appropriate.

Preservation of the vagus nerve during gastrectomy has been explored as a strategy to mitigate postgastrectomy syndromes, such as diarrhea, dumping syndrome, and weight loss. ¹⁸ Specifically, preserving the hepatic branch of the vagus nerve has been associated with maintaining bile secretion and digestive function, thereby reducing the risk of gallstone formation after gastrectomy. ¹⁹ However, despite these potential benefits, the preservation of the celiac branch of the vagus nerve declined significantly between 2014 and 2021 (p < 0.001), with only 9.6% of institutions preserving it in the latter survey. The decline in vagus nerve preservation, particularly the celiac branch, likely stems from concerns regarding the uncertain benefits, oncological safety, and technical challenges associated with this procedure (Table 7).

Total gastrectomy, though often necessary for advanced gastric cancer, results in the complete loss of gastric function, leading to severe postgastrectomy syndromes and reduced postoperative QOL. ²⁰ TGJP has been developed as an option to alleviate these complications by creating a gastric substitute using the jejunum. While TGJP has demonstrated benefits such as reduced reflux, improved food intake, and better QOL compared to standard total gastrectomy, ²¹ , ²² its adoption remains limited. This is likely due to concerns over pouch‐related complications, which, despite being infrequent (3.9% in 2014 and 3.5% in 2021), include issues like pouch dilation and outlet obstruction, primarily caused by oversized pouches or technical errors like twisted or adhesed efferent jejunal limbs. The recent approval of TGJP for insurance coverage in 2022 may promote wider acceptance of this technique. Additionally, growing evidence from clinical studies and meta‐analyses supports TGJP as a viable approach to enhance QOL in patients requiring total gastrectomy. ²¹ , ²² Careful surgical technique, including appropriate pouch size and prevention of limb twisting, is crucial for optimizing outcomes and minimizing complications.

Most surgeons agree that further advancements in gastrectomy techniques are essential to mitigating postgastrectomy syndromes and improving patient QOL. While proximal gastrectomy and SRDG have gained significant support, other procedures, such as PPG, vagus nerve preservation, and TGJP, continue to face challenges related to unclear benefits, oncological concerns, and technical complexity (Table 7). To encourage broader adoption of these function‐preserving and reconstructive procedures, more robust clinical evidence is needed. Recent innovations, such as specialized questionnaires for evaluating gastrectomy procedures, ²³ provide detailed insights into patient experiences and outcomes. ⁴ , ⁸ , ¹¹ , ¹³ , ¹⁴ , ²⁰ , ²² , ²⁴ , ²⁵ , ²⁶ , ²⁷ Additionally, advanced diagnostic tools like body composition analysis, ²⁷ continuous glucose monitoring, ²⁸ and high‐resolution esophageal impedance manometry ²⁶ offer more comprehensive assessments of postoperative outcomes. These tools enable a multi‐dimensional evaluation of the efficacy and safety of different gastrectomy procedures. Future research incorporating these new tools will be critical in validating the benefits of these procedures, facilitating wider adoption, and ultimately enhancing postoperative QOL for gastric cancer patients.

The incidence of AEGJ has been steadily increasing in Japan, likely due to declining Helicobacter pylori infection rates and the Westernization of dietary habits. Previous studies have reported an increase in surgeries for AEGJ between 2001 and 2010. ²⁹ Our survey further corroborates this trend, demonstrating a sustained rise in AEGJ surgeries over the subsequent decade (2011–2020), reflecting a continuous upward trajectory in these cases over the past 20 years. Despite the increase in AEGJ cases and the Japanese Gastric Cancer Treatment Guidelines (ver. 6; 2021) outlining surgical approaches and lymph node dissection algorithms for AEGJ, ³ there is still limited guidance on the optimal surgical and reconstructive strategies to maximize postoperative QOL. While proximal gastrectomy is generally preferred over total gastrectomy for AEGJ, some studies report that the postoperative QOL following proximal gastrectomy for AEGJ may be comparable to that of total gastrectomy ²⁵ and inferior to that for upper gastric cancer. ²⁴ Further research is warranted to determine the most effective gastrectomy procedures for improving postoperative QOL in AEGJ patients.

Endoscopic submucosal dissection (ESD) remains the preferred treatment for early gastric cancer, as it preserves the whole stomach and achieves excellent postoperative QOL. ³⁰ However, for patients ineligible for ESD, function‐preserving surgeries like proximal gastrectomy and PPG, though better than standard gastrectomy, still lead to some degree of postgastrectomy syndromes. ⁴ , ¹⁴ Local resection combined with sentinel node navigation surgery presents a potential alternative, allowing for minimal resection while ensuring lymph node assessment and achieving wider resection margins than ESD. This approach is expected to offer superior QOL compared to function‐preserving procedures such as proximal gastrectomy and PPG. ²⁰ Our survey indicates that many surgeons support the local resection of the stomach with use of sentinel node navigation surgery for early‐stage gastric cancer (cT1N0M0, ≤4 cm) in non‐ESD candidates, suggesting that it may become a standard option in the future. This technique could offer a balance between effective treatment and improved QOL for patients who are not suitable for ESD.

This study has several limitations. First, the response rates from institutions affiliated with the Japanese Society for Gastro‐surgical Pathophysiology were 56% in 2014 and 74% in 2021, which may limit the generalizability of the findings across all Japanese institutions. Second, while the surveys provide valuable insights into gastrectomy practices and trends, they do not assess the direct impact of these procedures on postoperative QOL. Third, in this study, the data from institutions that responded to both surveys (2014 and 2021) were analyzed together with those that responded to only one survey. While this approach enables a comprehensive analysis, it may introduce statistical limitations due to the mixed nature of the dataset. Specifically, potential biases may arise from analyzing paired data and independent data simultaneously, which could compromise the statistical independence of certain comparisons. Readers should interpret the findings with caution, acknowledging that the statistical methods applied represent a pragmatic compromise to balance the complexity of analysis with the scope of the study. Future studies should incorporate both clinical outcomes and QOL measures to provide a more comprehensive understanding of gastrectomy's impact.

In conclusion, this study highlights the evolution of gastrectomy practices in Japan over the past 7 years. Despite these advancements, there remains a need for more rigorous evidence supporting the benefits of function‐preserving and reconstructive gastrectomies, particularly those that are underutilized. As new diagnostic tools and assessment methods become available, future research will be critical to ensure that the most effective, safe, and patient‐centered surgical procedures, ultimately leading to more widespread adoption and better postoperative QOL for gastric cancer patients.

AUTHOR CONTRIBUTIONS

Koji Nakada: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; writing – original draft; writing – review and editing. Hideyuki Kashiwagi: Conceptualization; funding acquisition; project administration; writing – review and editing. Shinichi Kinami: Methodology; writing – review and editing. Hiroharu Yamashita: Methodology; writing – review and editing. Nobuyoshi Hanyu: Conceptualization; writing – review and editing. Atsushi Oshio: Formal analysis; writing – review and editing. Michio Kaminishi: Supervision; writing – review and editing. Yasuyuki Seto: Supervision; writing – review and editing.

FUNDING INFORMATION

The funding for this study was provided by the presidents of the 44th (2014) and 51st (2021) Annual Meetings of the Japanese Society for Gastro‐surgical Pathophysiology (H.K. and K.N.).

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest relevant to this article, except that author H.Y. serves as an editorial board member of Annals of Gastroenterological Surgery.

ETHICS STATEMENT

Approval of the research protocol by an Institutional Reviewer Board: N/A.

Informed Consent: N/A.

Registry and the Registration No. of the study/Trial: N/A.

Animal Studies: N/A.

Nakada K, Kashiwagi H, Kinami S, Yamashita H, Hanyu N, Oshio A, et al. Current status, trends, and controversies in the selection of gastrectomy procedures: Insights from two nationwide questionnaire surveys conducted over a 7‐year interval in Japan. Ann Gastroenterol Surg. 2025;9:903–919. 10.1002/ags3.70015

DATA AVAILABILITY STATEMENT

The data that supports the findings of this study are available in the tables of this article.