Nutritional and life-quality consequences of aboral pouch construction after total gastrectomy: a randomized, controlled study

Effect of Four Main Gastrectomy Procedures for Proximal Gastric Cancer on Patient Quality of Life: A Nationwide Multi-Institutional Study

PURPOSE

This study aimed to examine the effects of 4 main types of gastrectomy for proximal gastric cancer on postoperative symptoms, living status, and quality of life (QOL) using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

MATERIALS AND METHODS

We surveyed 1,685 patients with upper one-third gastric cancer who underwent total gastrectomy (TG; n=1,020), proximal gastrectomy (PG; n=518), TG with jejunal pouch reconstruction (TGJP; n=93), or small remnant distal gastrectomy (SRDG; n=54). The 19 main outcome measures (MOMs) of the PGSAS-45 were compared using the analysis of means (ANOM), and the general QOL score was calculated for each gastrectomy type.

RESULTS

Patients who underwent TG experienced the lowest postoperative QOL. ANOM showed that 10 MOMs were worse in patients with TG. Four MOMs improved in patients with PG, while 1 worsened. One MOM was improved in patients with TGJP versus 8 MOMs in patients with SRDG. The general QOL scores were as follows: SRDG (+39 points), TGJP (+6 points), PG (+3 points), and TG (-1 point).

CONCLUSIONS

The TG group experienced the greatest decline in postoperative QOL. SRDG and PG, which preserve part of the stomach without compromising curability, and TGJP, which is used when TG is required, enhance the postoperative QOL of patients with proximal gastric cancer. When selecting the optimal gastrectomy method, it is essential to understand the characteristics of each and actively incorporate guidance to improve postoperative QOL.

Intracorporeal bi-directional pouch jejunojejunostomy following Roux-en-Y anastomosis: a simple reconstruction technique using an endoscopic linear stapler

Introduction

Intracorporeal pouch jejunojejunostomy (JJ) is a technically challenging procedure during totally laparoscopic gastrectomy (TLG).

Aim

This study introduced a new method involving the construction of an intracorporeal bi-directional pouch JJ using an endoscopic linear stapler and analyzed the surgical outcomes of this method, including JJ complications.

Material and methods

We retrospectively reviewed the medical records of 168 patients who underwent laparoscopic gastrectomy with intracorporeal bi-directional pouch JJ between November 2017 and October 2018 at Asan Medical Center.

Results

The construction of an intracorporeal bi-directional pouch JJ took an average of 10 min. No postoperative bleeding or anastomotic strictures related to JJ reconstruction occurred after this procedure. No mortality occurred during follow-up.

Conclusions

Intracorporeal bi-directional pouch JJ using an endoscopic linear stapler is a safe and simple procedure. It is a feasible option to reduce JJ stricture after TLG in patients with gastric cancer.

The clinical effectiveness of the method by establishing a proximal jejunum pouch after laparoscopic total gastrectomy: A propensity score-based analysis

BACKGROUND

In this study, we propose an improved Roux-en-Y (RY) surgical method by constructing a proximal jejunum pouch (PP-RY). Postoperative results were evaluated among patients with gastric cancer who underwent PP-RY and standard RY anastomosis.

METHODS

The clinical data of patients with gastric cancer who underwent laparoscopic total gastrectomy (LTG) in our center from May 2019 to May 2020 were collected retrospectively. We compared the short-term results of patients in the PP-RY and RY groups using 1:1 propensity score matching (PSM).

RESULTS

A total of 317 patients were selected, including those who received RY (n = 249) or PP-RY (n = 68) after LTG. After PSM, both groups had a sample size of 68. During the one-year follow-up period, the incidences of postoperative dumping syndrome (5.6%) and reflux esophagitis (14.8%) were significantly lower in the PP-RY group (P = 0.001 and P = 0.010, respectively). Weight loss (6.5 ± 2.0 kg) and albumin decrease (0.2 ± 0.1 g/dl) were significantly lower (P = 0.038 and P < 0.001, respectively), and the prognostic nutritional index (PNI) was significantly higher in the PP-RY group (P = 0.009). In the QLQ-C30 scale, the degree of anorexia in the PP-RY group was significantly lower than that in the RY group (P＜0.05). In the QLQ-STO22 scale, chest and abdomen pain, dietary restriction, and anxiety were significantly lower in the PP-RY group (all P＜0.05).

CONCLUSION

PP-RY can lead to obvious improvements in nutritional status, reduce short-term complications, and improve quality of life (QoL) for patients after LTG.

Ileocolic Interposition as a Gastric Substitute in Patients with Total Gastrectomy; Case Series and Literature Review

Background: The standard method for reconstruction after total gastrectomy is Roux-en-Y reconstruction, which has several negative points such as malabsorption. The most important reasons for weight loss in these patients are reserval insufficiency and reduction of food-digestive juice blending. We suggest that the creation of a food reserve with a natural conduit by ileocolic interposition may help the patient to have more normal diet habits and prevent severe weight loss. Methods: The study enrolled 8 patients with proximal gastric cancer, who underwent total gastrectomy with omentectomy and D2 lymphadenectomy. Then, the ileocolic segment with its vasculature was prepared and the anastomosis was done like right colon interposition between esophagus and duodenum. Intraoperative and postoperative events and also nutritional conditions were recorded. Results: Among 8 patients enrolled in the study, not an intraoperative bad event nor anastomotic site leakage, abscess formation, or other significant post-operative complication were seen. Except for the first two patients, the rest did not suffer from dysphagia. None of the patients suffered from delayed, chronic, or uncontrolled vomiting. All patients experienced weight loss postoperatively but after 2 months, they gained weight. Barium examination and also upper endoscopy revealed that the patients had normal reserval volume, no evidence of erosion or ulceration, no evidence of biliary esophagitis or reflux, and absence of tumor relapse. Conclusions: Because of the nutritional benefits of ileocolic interposition after total gastrectomy in gastric cancer treatment, it can be used as an acceptable alternative method of reconstruction in a subgroup of selected patients.

Utility of continuous glucose monitoring following gastrectomy

BACKGROUND

Glucose fluctuation after gastrectomy represented by dumping syndrome is a well-known post-gastrectomy syndrome that negatively impacts patient quality of life. However, the current methods of post-gastrectomy glucose monitoring do not comprehensively capture the postoperative blood glucose fluctuations that characterize this.

METHODS

We used a continuous glucose monitoring (CGM) system to document the glycemic profiles of patients undergoing gastrectomy and compared these between patients undergoing distal gastrectomy (DG) and total gastrectomy (TG). To evaluate post-gastrectomy syndromes, including dumping syndrome, we used the Post-gastrectomy Syndrome Assessment Scale 37-item questionnaire. The glycemic profiles were also compared using this tool.

RESULTS

We studied 57 patients who had undergone DG and 13 who had undergone TG between September 2017 and September 2019. Our results revealed larger diurnal glycemic variability and longer periods of nocturnal hypoglycemia after gastrectomy. The dumping score was worse in the TG than in the DG group (TG 2.4 ± 1.4 vs. DG 1.3 ± 1.2, P = 0.0061). Importantly, 30 of 57 DG patients (52.6%) and 5 of 13 TG patients (38.5%) experienced postprandial hypoglycemia following hyperglycemia without hypoglycemic symptoms. There was no correlation between the dumping symptom score and glycemic variability (ρ = 0.0545, P = 0.6662).

CONCLUSIONS

CGM demonstrated diurnal glycemic variability and nocturnal hypoglycemia in patients undergoing gastrectomy. Because some hypoglycemic patients did not develop symptoms and glycemic variability was not necessarily associated with dumping symptom, dumping syndrome must only partially explain the postoperative glucose fluctuations.

Quality of Life After Curative Resection for Gastric Cancer: Survey Metrics and Implications of Surgical Technique

Gastric cancer is one of the most common cancers worldwide, and radical gastrectomy is an integral component of curative therapy. With improvements in perioperative morbidity and mortality, attention has turned to short- and long-term post-gastrectomy quality of life (QoL). This article reviews the common psychometric surveys and preference-based measures used among patients following gastrectomy. It also provides an overview of studies that address associations between surgical decision-making and postoperative health-related QoL. Further attention is focused on reported associations between technical aspects of the operation, such as extent of gastric resection, minimally-invasive approach, pouch-based conduits, enteric reconstruction, and postoperative QoL. While there are several randomized studies that include QoL outcomes, much remains to be explored. The relationship between symptom profiles and preference-based measures of health state utility is an area in need of further research.

Long-term quality of life and nutrition status of the aboral pouch reconstruction after total gastrectomy for gastric cancer: a prospective multicenter observational study (CCOG1505)

BACKGROUND

Several efforts have been made to alleviate harms and symptoms after gastrectomy for gastric cancer. We previously conducted a randomized controlled trial (CCOG1101) to compare quality of life (QOL) and nutritional status between Roux-en-Y (RY) and aboral pouch (AP) reconstructions for up to 1 year after total gastrectomy. However, long-term outcomes after AP reconstruction remain unclear.

METHODS

A prospective multicenter observational study was conducted to compare QOL, body composition, and nutritional indicators between the RY and AP reconstructions at 5 years after surgery among patients who were enrolled in the CCOG1101 trial. QOL was assessed by the PGSAS-37 questionnaires as well as the EORTC QLQ-C30 and STO22.

RESULTS

Sixty patients (31 for RY and 29 for AP) were recruited for analysis. There were no significant differences in baseline and perioperative characteristics between the two groups. No significant differences were found in the EORTC QLQ-C30 global health status and functional scales. Regarding symptom scales in the QLQ-C30 and STO22, a more favorable score for the diarrhea scale was observed in the AP group. Diarrhea was also the only item in the PGSAS-37 questionnaires in which significant benefit of AP was observed. Body weight and lean body mass continued to decrease throughout the postoperative 5 years in both groups. None of the conventional nutritional indicators using the serum samples showed significant difference between the two groups.

CONCLUSIONS

Long-term observation suggested little benefit of AP reconstruction after total gastrectomy other than in alleviating diarrhea.

Long-Term Consequences of Total Gastrectomy: Quality of Life, Nutritional Status, Bacterial Overgrowth and Adaptive Changes in Esophagojejunostomic Mucosa

OBJECTIVES

The aim of the study was to evaluate long-term quality of life and adaptive changes in the mucosa of the proximal section of the small intestine used for esophagojejunostomy reconstruction in stomach cancer patients after total gastrectomy.

MATERIAL AND METHODS

Thirty-one patients who had undergone stomach cancer-related total gastrectomy were included in the study, which spanned a period of 48 to 127 months (79.6 months on the average) after the surgery. The analysis included: a) evaluation of selected biochemical parameters; b) microbiological evaluation of esophagojejunostomic area; c) evaluation of adaptive changes in esophagojejunostomic mucosa using light and electron microscopy; d) quality of life evaluation with a Troidl questionnaire.

RESULTS

Quality of life was subjectively rated as good or very good by almost all subjects. The analyzed biochemical parameters were within the range of normal values in all the subjects with the exception of mild abnormalities in alkaline phosphatase and vitamin B12 levels in some patients. Microbiological examination of mucosal specimens from below the esophagojejunostomy revealed significant bacterial flora overgrowth in all the patients, with streptococci being the most abundant species. Light and electron microscopy examination of the epithelium confirmed it was normal and characteristic of a healthy small intestine.

CONCLUSIONS

Long-term quality of life in patients after complete stomach resection is considered good or very good, irrespective of the reconstruction method used, and the esophagojejunostomic mucosa of the reconstructed area is normal and typical for a healthy small intestine.

Quality of life and nutritional consequences after aboral pouch reconstruction following total gastrectomy for gastric cancer: randomized controlled trial CCG1101

BACKGROUND

Total gastrectomy has detrimental effects on postoperative nutritional status and quality of life (QOL), but it is often unavoidable in the treatment of gastric cancer. Roux-en-Y (RY) is the most common reconstruction method following total gastrectomy. Trials to explore other means of reconstruction have been conducted but have failed to identify a method that is globally accepted.

METHODS

Aboral pouch reconstruction (AP), in which an anisoperistaltic jejunal pouch is created in the Y limb of the RY reconstruction, is considered effective and technically feasible. A prospective randomized trial was conducted to compare AP with RY. Gastric cancer patients requiring total gastrectomy for R0 resection were randomly assigned during surgery to receive either RY (n = 51) or AP (n = 49). Postoperative QOL as assessed by the EORTC QLQ-C30 and STO22, body composition, and morbidity were compared between the two reconstruction methods. The physical functioning score of the QLQ-C30 was selected as the primary endpoint.

RESULTS

The incidences of postoperative complications were similar between the two groups (29 % in the RY group and 27 % in the AP group). No significant difference was observed in the physical functioning score, and the superiority of AP was demonstrated only for the nausea and vomiting score at 12 months (p = 0.041) and the reflux score at 1 month (p = 0.036). No significant differences were observed in body composition or serum biochemistry.

CONCLUSIONS

Although AP was safely implemented, no increased benefits in nutritional or QOL-related parameters were observed for this method over RY within 12 months postoperatively.

Assessment of patient-reported outcome measures in the surgical treatment of patients with gastric cancer

Background

Gastric cancer is responsible for 10 % of all cancer-related deaths worldwide. With improved operative techniques and neo-adjuvant therapy, survival rates are increasing. Outcomes of interest are shifting to quality of life (QOL), with many different tools available. The aim of this study was to assess which patient-reported outcome measures (PROMs) are used to measure QOL after a gastrectomy for cancer.

Methods

A comprehensive search was conducted for original articles investigating QOL after gastrectomy. Two authors independently selected relevant articles, conducted clinical appraisal and extracted data (P.J. and J.S.).

Results

Out of 3414 articles, 26 studies were included, including a total of 4690 patients. These studies included ten different PROMs, which could be divided into generic, symptom-specific and disease-specific questionnaires. The EORTC and the FACT questionnaires use an oncological overall QOL module and an organ-specific module. Only one validation study regarding the use of the EORTC after surgery for gastric cancer was available, demonstrating good psychometric properties and clinical validity.

Conclusions

A great variety of PROMs are being used in the measurement of QOL after surgery for gastric cancer. A questionnaire with a general module along with a disease-specific module for the assessment of QOL seems most desirable, such as the EORTC and the FACT with their specific modules. Both are developed in different treatment modalities, such as in surgical patients. EORTC is the most widely used questionnaire and therefore allows for comparison of new studies to existing data. Future studies are needed to assess content validity in surgical gastric cancer patients.

Comparison of Quality of Life and Nutritional Status in Gastric Cancer Patients Undergoing Gastrectomies

The aim of this study was to compare the quality of life (QoL) depending on the postoperative survival period or nutritional status in gastric cancer patients. Surviving gastric cancer patients (n = 222) after the gastrectomy were included in the study at Soonchunhyang University Bucheon Hospital from April 2010 to August 2012. The Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and a gastric cancer-specific module, the EORTC QLQ-STO22, were used to assess the QoL. The postoperative survival period of the patients fell into two groups; the less-than-1-year group or the more-than-1-year group, and the nutritional status of the patients fell into three groups by a score of patient generated-subjective global assessment (SGA)-A, B, and C. As a result, the rate of malnutrition was 34.5% in the less-than-1-year group and 19.8% in the more-than-1-year group, respectively. Score for the fatigue (p = 0.006), loss of appetite (p = 0.002), reflux (p = 0.027) and body image (p = 0.004) in which the QoL was significantly lower in the less-than-1-year group than in the more-than-1-year group. The score of QoL according to the nutritional status of all subjects, overall health status (p = 0.043), physical functioning (p = 0.016), fatigue (p = 0.006), pain (p = 0.028), loss of appetite (p = 0.017), reflux (p = 0.003), eating restriction (p = 0.002), anxiety (p = 0.010), and body image (p = 0.001) was significantly lower in the SGA-C group than in other SGA groups. These results suggest that the nutritional status of the gastrectomy patients with stomach cancer may impact on their QoL. It is necessary to to develop nutritional intervention to improve QoL in gastric cancer patients with postoperative malnutrition.

Pouch size influences clinical outcome of pouch construction after total gastrectomy: A meta-analysis

AIM: To assess the clinical significance of pouch size in total gastrectomy for gastric malignancies.

METHODS: We manually searched the English-language literature in PubMed, Cochrane Library, Web of Science and BIOSIS Previews up to October 31, 2013. Only randomized control trials comparing small pouch with large pouch in gastric reconstruction after total gastrectomy were eligible for inclusion. Two reviewers independently carried out the literature search, study selection, data extraction and quality assessment of included publications. Standard mean difference (SMD) or relative risk (RR) and corresponding 95%CI were calculated as summary measures of effects.

RESULTS: Five RCTs published between 1996 and 2011 comparing small pouch formation with large pouch formation after total gastrectomy were included. Eating capacity per meal in patients with a small pouch was significantly higher than that in patients with a large pouch (SMD = 0.85, 95%CI: 0.25-1.44, I² = 0, P = 0.792), and the operative time spent in the small pouch group was significantly longer than that in the large pouch group [SMD = -3.87, 95%CI: -7.68-(-0.09), I² = 95.6%, P = 0]. There were no significant differences in body weight at 3 mo (SMD = 1.45, 95%CI: -4.24-7.15, I² = 97.7%, P = 0) or 12 mo (SMD = -1.34, 95%CI: -3.67-0.99, I² = 94.2%, P = 0) after gastrectomy, and no significant improvement of post-gastrectomy symptoms (heartburn, RR = 0.39, 95%CI: 0.12-1.29, I² = 0, P = 0.386; dysphagia, RR = 0.86, 95%CI: 0.58-1.27, I² = 0, P = 0.435; and vomiting, RR = 0.5, 95%CI: 0.15-1.62, I² = 0, P = 0.981) between the two groups.

CONCLUSION: Small pouch can significantly improve the eating capacity per meal after surgery, and may improve the post-gastrectomy symptoms, including heartburn, dysphagia and vomiting.

Preservation versus non-preservation of the duodenal passage following total gastrectomy: a systematic review

BACKGROUND

Various reconstruction procedures have been proposed for restoring the alimentary tract continuity after total gastrectomy. However, so far there is no consensus on the ideal post-gastrectomy reconstruction procedure. The necessity of preserving the duodenal passage is one of the major focuses of the debate concerning gastrointestinal reconstruction and is the objective of this study.

METHODS

A systematic literature search of PubMed, EMBASE, the Cochrane Library, SCI, and Chinese Biomedical Literature Database (CBM) was carried out before March 2012 to obtain studies of randomized controlled trials (RCT). Analysis was performed using RevMan 5.0 software.

RESULTS

Nine RCTs involving 642 participants met the selection criteria. The results of the meta-analyses showed that operative mortality and morbidity were not significantly different between the two procedures (preservation vs. non-preservation of duodenum). However, operative time was considerably prolonged by preserving the duodenal passage. Patients in the preservation group had an improved nutritional parameters (body weight, levels of serum iron and hemoglobin) in the short term (<6 months) after surgery. Beneficial effect on preventing postgastrectomy symptom (heartburn, dumping syndrome) was not found by maintaining the duodenal passage throughout a 2-year follow-up. Moreover, a qualitative measurement showed that no significant quality of life improvement for patients with a preserved duodenal passage.

CONCLUSION

This systematic review failed to demonstrate obvious advantage in preserving duodenal passage after total gastrectomy.

[Postgastrectomy symptoms following total gastrectomy with or without preservation of the duodenal passage]

INTRODUCTION

Total gastrectomy leads to decreased quality of life, which is characterized by different symptoms of the postgastrectomy syndrome. Aim of this study was to investigate the correlation of different alimentary symptoms and habits in correlation with the reconstruction type after total gastrectomy.

PATIENTS AND METHODS

Between 2005-2009 34 patients after total gastrectomy for gastric cancer were evaluated with questionnaires. Twenty two had a standard Roux-en-Y reconstruction, while 12 Longmire type jejunal interposition. Early dumping syndrome was investigated with the Sigstad score.

RESULTS

Most of the investigated parameters were similar in Roux-en-Y and Jejunal Interposition patients. Early dumping syndrome however occurred significantly less frequantly after jejunal interposition.

CONCLUSION

Preservation of the duodenal passage after total gastrectomy reduces the prevalence of early dumping.

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial

BACKGROUND

The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial.

METHODS

A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups.

RESULTS

After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group.

CONCLUSIONS

Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

[Quality of life of patients with cancer of the oesophagus and stomach]

The study of the health related quality of life in patients with digestive tract cancer, and particularly in those with tumours of the oesophagus and stomach, provides useful information for selecting the most suitable therapeutic option. It may also be used to predict the impact of the disease and its possible treatments on the physical, emotional and social condition of the patient. Various sensitive and reliable tools have been developed over the past decades that are capable of measuring the quality of life of patients; the use of questionnaires has made it easier to exchange information between the patient and the doctor. The pre- and post-operative variations in the quality of life in patients with oesophageal-gastric cancer are of prognostic value on the outcome of the disease. For all these reasons, the health related quality of life is currently considered, along with disease free survival and absence of recurrences, one of the most important parameters in order to assess the impact on the patients of a particular oncological treatment. The aim of this article is to review the role of the health related quality of life assessment, as well as the various tools which are available to measure it in patients with oesophageal-gastric cancer.

Postoperative quality of life: development and validation of the "Dysfunction After Upper Gastrointestinal Surgery" scoring system

BACKGROUND

Although postoperative quality of life is an important outcomes measure, few tools exist to evaluate patients specifically after upper gastrointestinal surgery. The previously developed Dysfunction After Upper Gastrointestinal Surgery (DAUGS)32 scoring system has been further refined to include just 20 items. This study was undertaken to validate the refined evaluation tool.

STUDY DESIGN

The study was performed as a survey, administered to patients after upper gastrointestinal resection at 3 separate institutions.

RESULTS

The DAUGS20 score after gastrectomy (n = 662) was 27.8 and that after esophagectomy (n = 221) was 36.1, showing a significant difference (p < 0.05). The score after distal gastrectomy (n = 282) was 25.4 and that after total gastrectomy (n = 149) was 32.0, showing a significant (p < 0.05) difference. The α coefficient of all items on the DAUGS20 system was 0.904 and Cronbach's α coefficients of the subscales were 0.612 to 0.856, demonstrating high reliability of this evaluation tool. In addition, 7 factors were extracted from the 20 items using definitive factor analysis, to verify validity.

CONCLUSIONS

Patient quality of life should be evaluated as an outcomes measure after surgical resection for cancer, just as overall survival is analyzed. The DAUGS20 score is reliable, has validity in the evaluation of postoperative patients, and is a valuable tool to assess patient quality of life after upper gastrointestinal surgery for cancer.

Distal pouch reconstruction with transverse jejunoplasty after experimental gastrectomy

PURPOSE

Various reconstruction methods with or without reservoir formation after total gastrectomy have been established. Transverse intestinoplasty has benefits as a functional peristalsis modification in rectal resections. In this study, we evaluate a distal pouch combined with a transverse jejunoplasty compared to standard Roux-en-Y reconstruction.

METHODS

Total gastrectomy was performed on 23 pigs randomly assigned to 3 reconstruction groups-group 1 (n = 7): esophagojejunostomy without a pouch, group 2 (n = 8): esophagojejunostomy with a distal pouch, and group 3 (n = 8): distal pouch with a transverse jejunoplasty. Seven days postoperatively, weight was measured, and X-ray examinations were conducted for 1 h after oral contrast medium application. Blood glucose levels after oral glucose intake and the volume of the pouch loop were evaluated.

RESULTS

Upper jejunal passage was delayed and the mean volume of the jejunal loop increased by pouch formation compared to controls (p < 0.05). Body weight was the best for the pouch group with jejunoplasty (-1.9 ± 0.8% vs. pouch alone -3.3 ± 2.4% vs. no pouch -7.5 ± 2.1%, p < 0.05).

CONCLUSIONS

The distal jejunal pouch after total gastrectomy offers advantages with respect to bowel passage and postoperative nutrition status compared to standard Roux-en-Y reconstruction. The combination of a distal pouch and transverse jejunoplasty may provide additional functional benefits.

Measurement and interpretation of patient-reported outcomes in surgery: an opportunity for improvement

BACKGROUND

Surgery may have a profound effect on patients' health-related quality of life (QOL). To be optimally useful, trials that seek to guide clinical decision making should measure outcomes that are important to patients and report the results in a clinically meaningful way. We sought to explore how researchers currently measure and interpret QOL in surgical trials, using gastric cancer as a case study.

METHOD

We performed a systematic review of randomized controlled trials (RCTs) of gastric cancer surgery published between 1966 and 2009 that included at least one patient-reported outcome (PRO). Investigators assessed trial eligibility and extracted data in duplicate using standardized forms, then resolved disagreements by consensus.

RESULTS

Our search identified 87 RCTs of gastric cancer surgery, of which 11 (13%) included at least one PRO. Ten RCTs measured one or more validated PROs, although six also included ad hoc measures. All manuscripts presented the results as raw scores and nine of the 11 trials identified a statistical difference between groups. All 11 manuscripts prominently reported the PRO results in the abstracts and conclusions, but only one discussed the clinical significance of the differences between groups.

CONCLUSIONS

Most RCTs of gastric cancer surgery do not include measures of QOL and those that do suffer from important limitations. RCTs would be more useful to surgeons and patients if authors measured PROs and utilized existing approaches to present the results of PROs in ways that provide an intuitive sense of the magnitude of effects.

A new pouch reconstruction method after total gastrectomy (pouch-double tract method) improved the postoperative quality of life of patients with gastric cancer

PURPOSE

Many reconstruction methods after total gastrectomy (TG) lead patients to dumping syndrome, reflux esophagitis, and poor postoperative quality of life (QOL). To improve patients' postoperative QOL after TG, we introduce a new reconstruction method named "pouch-double tract" (PDT).

METHODS

A prospective randomized study was performed between 2005 and 2007 in 29 patients who were diagnosed as stage I or II gastric cancers preoperatively. Patients were followed until the end of 2009. Conventional Roux-en-Y reconstruction (RY) was performed in 15 patients, and PDT was used in 14 patients. Postoperative patients' nutritional assessments and patients' QOL were compared between the groups.

RESULTS

PDT did not increase morbidity or mortality compared with RY. Patients in the PDT group did not complain of dumping and showed better postoperative food intake. Body weight recovered better in PDT than in RY.

CONCLUSION

PDT is safe and associated with better nutritional status compared with the RY.

Pouch vs. no pouch following total gastrectomy: meta-analysis and systematic review

OBJECTIVES

Whether reconstruction after total gastrectomy for gastric malignancies should be done with or without a pouch is a controversial issue in clinical research. There is still no consensus on the reconstruction technique of choice. The aim of this report was to assess the value of pouch formation as a gastric substitute after total gastrectomy compared with reconstruction techniques without a pouch.

METHODS

A systematic literature search of the Medline database and the Cochrane Library was carried out and a meta-analysis executed according to the Quality of Reporting Meta-Analyses (QUOROM) statement. Only randomized controlled trials (RCTs) comparing reconstruction techniques with and without a pouch were eligible for inclusion. All trials were independently assessed by two authors. Data on perioperative parameters, postgastrectomy symptoms, eating capability, body weight, and quality of life were extracted from the RCTs for meta-analysis using random-effects models for the calculation of pooled estimates of treatment effects.

RESULTS

Nine RCTs comparing Roux-en-Y reconstructions with and without pouch and four RCTs comparing jejunal interpositions with and without a pouch were included. The results of the meta-analyses show that additional pouch formation does not significantly increase morbidity or mortality and does not considerably extend the operating time or the hospital stay. Patients with a pouch complained significantly less of dumping and heartburn and showed a significantly better food intake postoperatively. Quality of life was significantly improved in patients with a pouch compared with patients without a pouch. This difference even increased over time from 6 to 12 and 24 months postoperatively.

CONCLUSIONS

This meta-analysis highlights some clinical advantages of pouch reconstruction after total gastrectomy.

Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction

AIM: To compare postoperative quality of life (QOL) in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy.

METHODS: QOL assessments that included functional outcomes (a 24-item survey about treatment-specific symptoms) and health perception (Spitzer QOL Index) were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy.

RESULTS: Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty (EA group); 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis (EP group); and 50 patients had reconstruction by esophagogastric end-to-end anastomosis (EE group). The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups.

CONCLUSION: Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.

Gastrointestinal transit, appetite, and energy balance in gastrectomized patients

BACKGROUND

Alterations in gastrointestinal tract physiology after gastrectomy may affect appetite and energy balance.

OBJECTIVE

The objective of this study was to examine energy balance, appetite, and gastrointestinal transit in subjects with gastrectomy.

DESIGN

Seven subjects with total gastrectomy (TG) and 14 subjects with partial gastrectomy (PG), who were free from signs of recurrent disease, and 10 healthy control subjects were studied. Resting energy expenditure (REE) was measured by indirect calorimetry and compared with REE predicted by the Harris-Benedict equation (mREE/pREE%). Gastrointestinal transit was measured by scintigraphy. Habitual food intake was assessed, and appetite was measured during scintigraphy after ingestion of a test meal (361 kcal).

RESULTS

Body mass index was not different among the groups. mREE/pREE% was higher in patients with PG (P < 0.01) than in control subjects. The TG group showed higher energy intake (P < 0.05) than the PG group and control subjects. Gastric emptying was faster in the PG group than in control subjects, and gastrointestinal transit was accelerated in both PG and TG groups. An intense, precocious postprandial fullness and a relatively early recovery of hunger and prospective consumption sensations were seen in these patients.

CONCLUSIONS

Patients with PG or TG have higher than predicted energy expenditure, which in TG seems to be compensated for by increased energy intake. These patients have preserved postprandial appetite responses and precocious postprandial fullness, which seem to be associated with disturbances in gastrointestinal transit of the ingested meal and are likely to be independent of vagal fiber integrity or stomach-released ghrelin.

Comparing aboral versus oral pouch with preserved duodenal passage after total gastrectomy: does the position of the gastric substitute reservoir count?

BACKGROUND

Total gastrectomy results in a significant weight loss, different postgastrectomy symptoms, and a reduction in quality of life. Elaborate surgical reconstruction methods are evaluated to improve results. The present study compares two types of reconstructions--an aboral pouch with preserved duodenal passage and an oral pouch with preserved duodenal passage--differing only in the site of the pouch.

METHODS

Twenty-eight patients entered the study. Primary outcome measures--body weight, body mass index, and quality of life, and secondary outcome measures--serum nutritional parameters, scintigraphic small-intestinal passage, and lipid and carbohydrate absorption were measured 6, 12, and 24 months after surgery.

RESULTS

No significant differences were found in anthropometric parameters or in quality of life between the groups. Regarding the secondary outcome measures, albumin levels were higher in the oral pouch group, while protein and immunoglobulin-A levels were higher in the aboral pouch group.

CONCLUSION

The site of the reservoir does not significantly influence the outcome after total gastrectomy and reconstruction with a preserved duodenal passage.

Optimal gastric pouch reconstruction post-gastrectomy

BACKGROUND

Gastric pouches have the potential to improve nutrition following total gastrectomy, compared with standard reconstruction. However, a consensus view of clinical benefit is not available, at least partly due to a lack of standardization of pouch design or size. This study was undertaken to identify optimal conditions for pouch design.

METHODS

A mathematical model was established and a porcine model constructed to evaluate the pressure/volume dynamics of the pouch. A "J" pouch was constructed at anastomotic lengths of 5, 10, 15, and 20 cm. Each pouch was distended with saline and the pressure/volume relationship established.

RESULTS

Mathematically, increasing the anastomotic length of the pouch to 15 cm increases the volume significantly; thereafter, there is minimal benefit of increasing the pouch length further. For smaller pouches (5 and 10 cm) a 350-to 400-ml volume (approximate meal volume in the elderly) is never achieved until higher pressures (45 cmH(2)O) are applied. However, in the larger pouches (15 and 20 cm) a 350-to 400-ml volume is readily achieved at basal pressures of 15 cmH(2)O.

CONCLUSION

Smaller pouches never achieve adequate volumes at basal pressures; accordingly, it is unlikely that they will lead to any clinical benefit. Further in-vivo studies should therefore be based upon 15-cm pouch designs.

[Searching for the optimal reconstructive methods following total gastrectomy]

Three prospective randomised studies and a clinical experiment were performed to study postoperative weight, body mass index, nutritional and immunological laboratory parameters, gut motility, lipid and carbohydrate absorption, quality of life and gastrointestinal hormone production after total gastrectomy with different reconstructions. The first trial compared Roux-en-Y to a newly introduced aboral pouch construction, while the second study compared these two methods and the aboral pouch reconstruction with a preserved duodenal passage version. Improved lipid absorption and quality of life was detected for the aboral pouch reconstruction. In addition to these, the duodenal passage preserving version resulted in a better iron metabolism, too. The third study compared the aboral pouch to conventional oral pouch, both with duodenal passage preserving versions. No significant difference was detected between these two groups. In the fourth study, a clinical experiment was performed examining pre- and postprandial glucose, insulin, cholecystokinin and somatostatin levels in patients recruited from the first two randomised trials. Significant differences were demonstrated between the various reconstruction types: the duodenal passage preserving reconstruction provided close to physiological cholecystokinin and somatostatin productions, while with duodenal exclusion these levels were abnormally raised.

Clinical results of various reconstructions employed after total gastrectomy

Methods of restoring continuity after total gastrectomy, particularly those creating a "reservoir," have led to many publications over the last 20 years. These publications are herein reviewed in an attempt to answer questions regarding the clinical value of a jejunal "reservoir". The conclusion we reached from this review was that such a reconstruction does reduce unpleasant symptoms, aids weight maintenance, and is a valuable operative approach.

Effects of nutritional support long time after total gastrectomy

BACKGROUND & AIMS

Long-term effects of total gastrectomy on nutritional status are not well known, neither is the role of nutritional support. Dietary counselling is usually individualized, but generally not well defined. We aimed to evaluate effects of individualized oral nutritional support long time after total gastrectomy.

METHODS

Dietary advice was given, aiming for an energy and protein rich diet, using ordinary food and liquid supplements tailored to individual needs and preferences. Counselling was repeated monthly. Body weight and a 4-day food record were obtained at baseline, and thereafter-at month 1, 3, 6 and 12. Body composition, resting and total energy expenditure were measured at baseline and at 12 months.

RESULTS

Thirteen of 15 included patients completed the study. Though a trend of weight gain was seen after 1 month, there was no significant weight change at 12 months as weight development was quite heterogeneous. Six patients who remained healthy during the study (all with BMI<25) gained weight (p<0.05), while five patients with intercurrent co-morbidity and two with initial BMI>25 lost weight or remained stable.

CONCLUSIONS

Nutritional intervention long time after total gastrectomy did not change body weight, body composition or energy metabolism. Intercurrent co-morbidity appeared to have a major impact on outcome, as the nutritional support was more effective in patients who remained healthy and had a BMI<25.

Comparing reconstruction with ileocecal graft to jejunal interposition pouch after total gastrectomy in rats

After total gastrectomy, the ileocecal graft may act as a reservoir and protect against reflux but give rise to transposition of the ileum and cause possible changes in bile acid metabolism and nutrition. This study compared the ileocecal graft and jejunal pouch. Male Wistar rats weighing 265 +/- 22 g were submitted to sham operation (S), ileocecal interposition graft (IIG), and jejunal pouch interposition graft (JP) after total gastrectomy. Eight weeks later, the esophagus was examined for evidence of esophagitis. Nutritional biochemistry and weight profile were documented preoperatively and 8 weeks after surgery. The oral glucose tolerance test was performed. Thirty-three rats were operated on and 30 survived for 8 weeks. Esophagitis occurred in seven JP rats. Body weight was significantly higher in IIG than in JP rats (p < .05). Normal glucose tolerance to intragastric glucose load was observed in sham and operated rats. JP rats had a significant decrease in serum albumin, glucose, transferrin, hemoglobin, iron, folate, and calcium, compared to sham (p < .05). Cobalamine was significantly lower in IIG rats than in JP rats (p < .05). In the IIG and JP groups, serum/hepatic total bile acid did not differ significantly from preoperative and sham values. In conclusion, the IIG interposition graft in rats prevented esophagitis, preserved nutrition, and did not interfere with enterohepatic total bile acid circulation.

Health-related quality of life measurement in randomized clinical trials in surgical oncology

PURPOSE

There is debate about the value of measuring health-related quality of life (HRQL) in clinical trials in oncology because of evidence suggesting that HRQL does not influence clinical decisions. Analysis of HRQL in surgical trials, however, may inform decision making because it provides detailed assessment of the immediate detrimental short-term impact of surgery on HRQL that needs to be considered against the long-term survival benefits and functional outcomes of surgery. This study evaluated whether HRQL in randomized trials in surgical oncology contributes to clinical decision making.

METHODS

A systematic review identified randomized trials in surgical oncology with HRQL. Trials were evaluated independently by two reviewers and the value of HRQL in clinical decision making was categorized in three ways: whether trial investigators reported that HRQL influenced final treatment recommendations, whether trial investigators reported that HRQL would be useful for informed consent, and whether HRQL was assessed robustly according to predefined criteria.

RESULTS

Thirty-three randomized trials with valid HRQL questionnaires were identified; 22 (67%) concluded that HRQL outcomes influenced treatment decisions or provided valuable data for informed consent, and seven of these trials had robust HRQL design. Another five trials had robust HRQL design but investigators reported that HRQL outcomes were not clinically important enough to influence treatment recommendations.

CONCLUSION

In surgical trials in oncology, HRQL informed clinical decision making. It is recommended that HRQL be included in relevant surgical trials, and that information be used to inform clinicians and patients about the impact of surgery on short- and long-term HRQL.

Quality of life after total or partial gastrectomy for primary gastric lymphoma

Up to 90% of patients with localized non-Hodgkin's lymphomas (NHL) in the gastrointestinal tract (GI) are cured and decreased use of radical surgery is favoured. Although quality of life (QOL) may impact treatment choice, little is known about QOL in gastric NHL survivors. The self-reported QOL (EORTC QLQ-C30 and a gastric module) and objective findings from upper GI endoscopy were evaluated in patients in complete remission after treatment for primary gastric NHL at the Norwegian Radium Hospital (NRH). Thirty-six (90%) patients completed the questionnaires, 33 (83%) met for endoscopy. Ten patients were treated with total gastrectomy, 17 with partial gastrectomy, while nine patients did not undergo surgery. Gastroscopy was normal in 55% of the non-gastrectomised patients, oesophagoscopy in 69%. Four patients had Barrett's metaplasia. QOL was not different from population values. Patients treated with total gastrectomy reported poorer emotional function, more diarrhoea and more food-related problems (p< or =0.05) compared with the others. Based on the higher level of digestive and food related problems after total gastrectomy, stomach-preserving surgery should be preferred whenever possible.

Proximal gastrectomy reconstructed by jejunal pouch interposition for upper third gastric cancer: prospective randomized study

Proximal gastrectomy with jejunal pouch interposition (PGJP) has been advocated as an alternative operation for upper third gastric cancer. However, there has been no prospective randomized trial comparing PGJP with total gastrectomy with Roux-en-Y esophagojejunostomy (TGRY). The aim of this study was to compare the short- and medium-term results of PGJP and TGRY in a randomized clinical trial. Fifty-one patients with upper third gastric cancer were randomized to either PGJP (n = 25) or TGRY (n = 26). Outcome measures were postoperative complications, nutritional status assessed by serum nutritional parameters, and postgastrectomy symptoms. There were no significant differences in operating time, hospital stay, and postoperative complications. Blood loss was significantly less in the PGJP group (P = 0.036). Nineteen patients (73%) in the TGRY group had one or more postgastrectomy symptoms, which was significantly more frequent than in the PGJP group (32%; P = 0.012). There were also significant differences between the two groups with regard to food intake, weight recovery, hemoglobin, and serum vitamin B12 levels in favor of PGJP. In conclusion, proximal gastrectomy with jejunal pouch interposition for upper third gastric cancer is safe, and is associated with a greater reduction in postgastrectomy symptoms and better nutritional status compared with conventional total gastrectomy.

Quality of life in gastric cancer

AIM: To summarize the empirical research on assessing quality of life (QOL) in patients with gastric carcinoma.

METHODS: Literature searches were conducted in MedLine from 1966 to February 2004.

RESULTS: Twenty-six studies were identified. QOL was used as an outcome measure in virtually all identified studies, such as those examining the effects of gastric cancer and various medical or surgical treatments in the patients. QOL was assessed mainly with generic measures; the social dimensions of QOL were largely neglected. The lack of gastric cancer-specific QOL measures hampers QOL research up to now. The gastric cancer-specific EORTC-QLQ-STO22 and the FACT-Ga are important additions to the arsenal of disease-specific QOL measures. In most of the studies, the label QOL is used for questionnaires, which only assess symptoms or performance status, or are physician-reported rather than patient-reported outcomes.

CONCLUSION: QOL in patients with gastric cancer deserves more systematic studies, especially as one of the outcome measures in randomized clinical trials. Results of studies that include QOL in patients with gastric cancer should be applied in clinical care, which aims at improving QOL of these patients.

Total gastrectomy with substitution of stomach by jejunal pouch with and without duodenal passage: study in rats

PURPOSE: A comparison was done between the F. Paulino jejunal pouch (FP) and a jejunal pouch (JP) as esophagus-duodenum interpositional graft, for replacing the stomach after total gastrectomy. It was investigated the effect of the two procedures on esophagus histology, nutritional state and serum gastrin in rats. METHODS: Male Wistar rats weighing 282±17g were randomly submitted to sham operation (S), FP and JP after total gastrectomy. After eight weeks the rats were killed with overdose of anesthetic and tissue was taken from the distal esophagus for histology. Serum levels of total proteins, albumin, iron, transferring, folate, cobalamine, calcium, as well as serum gastrin were determined. Survival was considered. RESULTS: Fourty six rats were operated and thirty survived for eight weeks. Five (33.3%) died after FP and 11 (52.3%) after JP (p<0.05). Postoperative esophagitis occurred in 6 JP rats. At 8th week, no difference was observed on body weight when compared FP and JP rats (p>0.05). The JP rats had a significant decrease in serum albumin, glucose, transferrin, iron, folate and calcium, compared to sham (p<0.05). Serum gastrin, iron and calcium were significantly higher in JP rats than in FP rats (p<0.05). In FP rats, transferrin and cobalamine showed significant decrease comparing the preoperative with 8th week levels (p<0.05). CONCLUSION: F. Paulino pouch in rats had lower mortality than JP, and esophagitis was not detected in it. JP rats had serum gastrin, iron and calcium unaffected, possibly because of preservation of duodenal passage.

Postgastrectomy syndromes--diagnosis and treatment

The stomach has a variety of functions that are lost with gastrectomy. Since nowadays a significant number of patients are long-term survivors, consequences of this loss need to be considered by gastroenterologists and surgeons alike. Abnormal transit, disturbed general nutrition and micronutrient deficiencies are the most common problems. The main resulting symptoms are early and late dumping, reflux esophagitis, weight loss, anemia, and osteopathy. It is not definitively clear if pouch reconstruction can really improve the situation. Dietary measures, rarely re-operation, and in particular adequate follow-up of metabolic and nutrition parameters with consequent substitution are the main therapeutic necessities.

Techniques of reconstruction after total gastrectomy for cancer

BACKGROUND

Jejunal pouch formation and restoration of duodenal transit have been suggested for reconstruction after total gastrectomy. Opinions about the clinical value vary.

METHODS

The literature was searched for prospective randomized trials comparing reconstructive procedures after total gastrectomy for malignancy. Reports with at least an English or German abstract were included. Immediate results were evaluated in terms of postoperative deaths and complications. Long-term outcome was analysed using trends in bodyweight and quality of life.

RESULTS

A total of 19 randomized trials including 866 patients was identified. The operative risk of total gastrectomy was low, with a median mortality rate of 0 (range 0-22) per cent, irrespective of the method of reconstruction. Neither gastric substitution nor restoration of duodenal transit was associated with significant procedure-related complications. Results for specific reconstructions varied considerably within and between individual trials. Jejunal pouch reconstruction, but not restoration of duodenal passage, was associated with improved food intake and a tendency for weight gain in the early postoperative months. A favourable perception of quality of life persisted in the long term in some studies.

CONCLUSION

Preservation of duodenal transit offers little clinical benefit. Construction of a small-bowel reservoir after total gastrectomy should be considered to improve early postoperative eating capacity, bodyweight and quality of life.

Total gastrectomy: options for the restoration of gastrointestinal continuity

Total gastric resection and the subsequent selection of the optimum procedure for reconstruction of the oesophageal-intestinal tract is a highly debated topic. Many different types of reconstruction have been proposed, but attempts to objectively validate the potential advantages of these techniques of have not produced any definitive conclusions. The main aim of reconstruction should be to maintain the nutritional status and quality of life of the patient, with the additional goal of achieving similar function to normal gut. In this review, we discuss the prospectively randomised studies of gastrointestinal reconstruction that were done between 1987 and 2002.

Aboral pouch with preserved duodenal passage--new reconstruction method after total gastrectomy

A new reconstruction method--the aboral pouch with preserved duodenal passage--has been introduced after total gastrectomy. After removal of the stomach, preparation of the Roux loop and construction of the esophago-jejunostomy, a jejuno-duodenostomy is performed approximately 50 cm away from the esophageal anastomosis between the Roux limb and the duodenal stump. Right below this second anastomosis, the Roux limb is closed with a stapling device to provide a unidirectional food passage through the duodenum. The aboral pouch is constructed as a side-to-side anastomosis between the Roux limb under the stapled segment and the aboral end of the Y limb. The advantages of the reservoir-constructing methods and the interposition methods are combined in this new reconstruction type. Our experiences of 17 cases having undergone this reconstruction method are presented.