Quality of life after total vs distal gastrectomy with Roux-en-Y reconstruction: Use of the Postgastrectomy Syndrome Assessment Scale-45

Function Preserving Gastrectomy and Quality of Life

Advances in gastric cancer screening have enabled earlier detection, shifting the focus of treatment toward preserving patients' quality of life (QoL). Function-preserving gastrectomy (FPG), including pylorus-preserving gastrectomy, proximal gastrectomy, and sentinel node navigation surgery, represents a paradigm shift in the surgical management of early gastric cancer. These techniques aim to balance oncological safety with the preservation of gastric function, mitigating postgastrectomy syndromes such as dumping syndrome, bile reflux, and nutritional deficiencies. QoL assessment tools, including EORTC QLQ-STO22, KOQUSS-40, and PGSAS-45, have become integral for evaluating patient-reported outcomes, providing insights into physical, emotional, and functional recovery. Although current evidence underscores the benefits of FPG, most studies are limited to East Asia, highlighting the need for multinational trials to validate these findings globally. FPG has demonstrated comparable short- and long-term oncological outcomes to conventional gastrectomy. Enhanced nutritional recovery and reduced gastrointestinal sequelae make FPG increasingly attractive. However, its widespread adoption is challenged by technical complexity, resource intensity, and the need for adequate surgical experience. The integration of advanced technologies, such as robotic surgery and artificial intelligence, coupled with personalized approaches, is expected to further optimize FPG outcomes. This review underscores the critical role of standardized QoL assessments, collaborative research, and technological innovations in advancing FPG as a cornerstone of patient-centered gastric cancer care.

Prognostic Relevance of the Proximal Resection Margin Distance in Distal Gastrectomy for Gastric Adenocarcinoma

BACKGROUND

The risk for recurrence in patients with distal gastric cancer can be reduced by surgical radicality. However, dispute exists about the value of the proposed minimum proximal margin distance (PMD). Here, we assess the prognostic value of the safety distance between the proximal resection margin and the tumor.

PATIENTS AND METHODS

This is a single-center cohort study of patients undergoing distal gastrectomy for gastric adenocarcinoma (2001-2021). Cohorts were defined by adequacy of the PMD according to the European Society for Medical Oncology (ESMO) guidelines (≥ 5 cm for intestinal and ≥ 8 cm for diffuse Laurén's subtypes). Overall survival (OS) and time to progression (TTP) were assessed by log-rank and multivariable Cox-regression analyses.

RESULTS

Of 176 patients, 70 (39.8%) had a sufficient PMD. An adequate PMD was associated with cancer of the intestinal subtype (67% vs. 45%, p = 0.010). Estimated 5-year survival was 63% [95% confidence interval (CI) 51-78] and 62% (95% CI 53-73) for adequate and inadequate PMD, respectively. Overall, an adequate PMD was not prognostic for OS (HR 0.81, 95% CI 0.48-1.38) in the multivariable analysis. However, in patients with diffuse subtype, an adequate PMD was associated with improved oncological outcomes (median OS not reached versus 131 months, p = 0.038, median TTP not reached versus 88.0 months, p = 0.003).

CONCLUSION

Patients with diffuse gastric cancer are at greater risk to undergo resection with an inadequate PMD, which in those patients is associated with worse oncological outcomes. For the intestinal subtype, there was no prognostic association with PMD, indicating that a distal gastrectomy with partial preservation of the gastric function may also be feasible in the setting where an extensive PMD is not achievable.

Useful of proximal gastrectomy with double-tract reconstruction in preventing glucose spikes

BACKGROUND

Volatile glucose levels after gastrectomy induce dumping syndrome, which adversely affects patient quality of life. This study aimed to evaluate the glycemic variability of proximal gastrectomy with double-tract reconstruction (PGDTR) as a function-preserving procedure.

METHODS

This study used a continuous glucose monitoring (CGM) system to record glycemic profiles of patients who underwent PGDTR or total gastrectomy (TG) and compared them. Moreover, this study evaluated postgastrectomy syndrome, including dumping symptoms, between the PGDTR and TG groups using the 37-item Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire.

RESULTS

Of note, 44 patients underwent PGDTR, and 42 patients underwent TG, which included more advanced cases. CGM results showed that the SD, relative SD, and maximum drop in glucose level between 30 min and 2 h after a meal were smaller in the PGDTR group than in the TG group (14.81 vs 22.40 mg/dL [P < .001], 0.14 vs 0.20 mg/dL [P < .001], and 42.06 vs 117.67 mg/dL [P < .001], respectively). For nocturnal glucose levels, SD and percentage time below the range were smaller in the PGDTR group than in the TG group (11.76 vs 15.16 mg/dL [P = .005] and 11.25% vs 35.27% [P < .001]). The PGDTR group generally performed better than the TG group on all the PGSAS-37 questionnaire items. Patients in the PGDTR group without food inflow into the remnant stomach showed similar CGM results as those in the TG group but with stronger dumping symptoms.

CONCLUSION

Food inflow into the remnant stomach is essential for PGDTR to be a function-preserving procedure as it leads to the control of dumping symptoms and lower glucose level spikes.

Short-term outcomes of distal gastrectomy versus total gastrectomy for gastric cancer under enhanced recovery after surgery: a propensity score-matched analysis

Enhanced recovery after surgery (ERAS) has been used safely and effectively in patients with gastric cancer. Our aim was to evaluate the short-term outcomes of total gastrectomy (TG) versus distal gastrectomy (DG) for gastric cancer under ERAS. A prospectively collected database of 1349 patients with gastric cancer who underwent TG or DG between January 2016 and September 2022 was retrospectively analyzed. Propensity score matching analysis was used at a ratio of 1:1 to reduce confounding effects, and perioperative clinical outcomes were compared between the two groups. The primary outcome was overall postoperative complications (POCs). Secondary outcomes comprised time to bowel function recovery, postoperative hospital stay, mortality, and 30-day readmission rate. Of 1349 identified patients, 296 (21.9%) experienced overall POCs. Before matching, multivariable analysis revealed that age, body mass index, diabetes, operation time, and extent of gastrectomy were independent risk factors for overall POCs. After matching, each group comprised 495 patients, and no significant differences were observed between the groups for all parameters except tumor location. Compared with TG, DG was associated with significantly earlier days to first flatus and to eating a soft diet, and shorter postoperative hospital stay (P < 0.05). The incidence of overall- and severe POCs (Clavien-Dindo grade ≥ IIIa) in the TG group was significantly higher vs. the DG group (P < 0.05). There was no significant difference in the number of days to eating a liquid diet, or mortality and 30-day readmission rates between the groups (P > 0.05). In the subgroup analysis for middle-third gastric cancer, the TG group experienced higher rates of overall- and severe POCs, with a longer postoperative hospital stay. Compared with DG, patients who underwent TG had higher POC rates, slower recovery of bowel function, and longer duration of hospitalization under ERAS. Therefore, caution is needed when initiating early feeding for patients who undergo TG.

Impact of the Aboral Pouch in Roux-en-Y Reconstruction after Laparoscopic Total Gastrectomy for Elderly Patients

Objectives

The number of elderly people with stomach cancer is increasing; therefore, minimally invasive surgical treatments are required. Elderly patients have multiple comorbidities and are prone to postoperative weight loss, nutritional disorders, Postgastrectomy syndrome (PGS), and decreased quality of life (QOL). Total gastrectomy is particularly associated with these complications, although aboral-pouch creation reportedly improves the condition by compensating for lost reservoir capacity. However, there is no consensus regarding its significance. This study aimed to investigate the impact of the aboral pouch on total gastrectomy outcomes in elderly patients.

Materials and Methods

Thirty-six patients who met the eligibility criteria, defined as elderly patients aged ≥75 years, were retrospectively analyzed. The patients had undergone Roux-en-Y reconstructions with an aboral pouch in laparoscopic total gastrectomy procedures performed at Juntendo University from July 2016 to June 2022. The main outcomes were postoperative nutritional status, PGS, and QOL.

Results

The average postoperative period was approximately 1 year (12.0 vs. 13.5 months, P=0.536), for 14 elderly and 22 non-elderly patients, respectively. Elderly patients had more comorbidities (78.5% vs. 40.9%, P=0.041). The outcome of nutritional status demonstrated no differences in weight-loss rate (-5.3% vs. -8.6%, P=0.651) or prognostic nutritional status (-7.9% vs. -5.9%, P=0.243). There was no significant difference in PGS and QOL between elderly and non-elderly patients.

Conclusions

Total gastrectomy with an aboral-pouch creation could be beneficial for elderly 43 patients from the perspective of postoperative nutritional status, PGS, and QOL.

Perioperative and Postoperative Continuous Nutritional Counseling Improves Quality of Life of Gastric Cancer Patient Undergoing Gastrectomy

Post-gastrectomy syndrome (PGS) and body weight loss (BWL) decrease quality of life (QOL) and survival of the patient undergoing gastrectomy. We have introduced perioperative and post-discharge continuous nutritional counseling (CNC) to prevent BWL and improve QOL after gastrectomy. In the present study, we evaluated the effect of CNC on QOL using the Post-gastrectomy Syndrome Assessment Scale-45 (PGSAS-45). Eighty-three patients with gastric cancer (GC) who underwent curative gastrectomy between March 2018 and July 2019 were retrospectively analyzed. Patients received either pre-discharge nutritional counseling alone (control group, n = 45) or CNC (CNC group, n = 38) after gastrectomy. QOL at 12 months after gastrectomy was compared between the two groups. In QOL assessment, change in body weight (-7.98% vs. -12.77%, p = 0.0057), ingested amount of food per meal (7.00 vs. 6.07, p = 0.042) and ability for working (1.89 vs. 2.36, p = 0.049) were significantly better in CNC group than control group. Multiple regression analysis showed that CNC was a significantly beneficial factor for abdominal pain subscale (p = 0.028), diarrhea subscale (p = 0.047), ingested amount of food per meal (p = 0.012), Ability for working (p = 0.031) and dissatisfaction at the meal (p = 0.047). Perioperative and postoperative CNC could improve QOL in the patient undergoing gastrectomy in addition to preventing postoperative BWL.

Trans-pacific multicenter collaborative study of minimally invasive proximal versus total gastrectomy for proximal gastric and gastroesophageal junction cancers

BACKGROUND

The current standard operation for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal extension is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to the loss of gastric functions such as production of ghrelin and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) can mitigate these problems by preserving gastric function. However, PG with direct esophagogastric reconstruction is associated with severe postoperative reflux, delayed gastric emptying, and poor quality of life (QoL). Minimally invasive PG (MIPG) with antireflux techniques has been increasingly performed by experts but is technically demanding owing to its complexity. Moreover, the actual advantages of MIPG over minimally invasive TG (MITG) with regards to postoperative QoL are unknown. Our overall objective of this study is to determine the short-term QoL benefits of MIPG. Our central hypotheses are that MIPG is safe and that patients have improved appetite after MIPG with effective antireflux techniques, which leads to an overall QoL improvement when compared with MITG.

METHODS

Enrollment of a total of 60 patients in this prospective survey-collection study is expected. Procedures (MITG versus MIPG, antireflux techniques for MIPG [double-tract reconstruction versus the double-flap technique]) will be chosen based on surgeon and/or patient preference. Randomization is not considered feasible because patients often have strong preferences regarding MITG and MIPG. The primary outcome is appetite level (reported on a 0-10 scale) at 3 months after surgery. With an expected 30 patients per cohort (MITG versus MIPG), this study will have 80% power to detect a one-point difference in appetite level. Patient-reported outcomes will be longitudinally collected (including questions about appetite and reflux), and specific QoL items, body weight, body mass index and ghrelin, albumin, and hemoglobin levels will be compared.

DISCUSSION

Surgeons from the US, Japan, and South Korea formed this collaboration with the agreement that the surgical approach to P/GEJ cancers is an internationally important but controversial topic that requires immediate action. At the completion of the proposed research, our expected outcome is the establishment of the benefit and safety of MIPG.

TRIAL REGISTRATION

This trial was registered with Clinical Trials Reporting Program Registration under the registration number NCI-2022-00267 on January 11, 2022, as well as with ClinicalTrials.gov under the registration number NCT05205343 on January 11, 2022.

Evaluating the identification of the extent of gastric cancer by over-1000 nm near-infrared hyperspectral imaging using surgical specimens

Significance

Determining the extent of gastric cancer (GC) is necessary for evaluating the gastrectomy margin for GC. Additionally, determining the extent of the GC that is not exposed to the mucosal surface remains difficult. However, near-infrared (NIR) can penetrate mucosal tissues highly efficiently.

Aim

We investigated the ability of near-infrared hyperspectral imaging (NIR-HSI) to identify GC areas, including exposed and unexposed using surgical specimens, and explored the identifiable characteristics of the GC.

Approach

Our study examined 10 patients with diagnosed GC who underwent surgery between 2020 and 2021. Specimen images were captured using NIR-HSI. For the specimens, the exposed area was defined as an area wherein the cancer was exposed on the surface, the unexposed area as an area wherein the cancer was present although the surface was covered by normal tissue, and the normal area as an area wherein the cancer was absent. We estimated the GC (including the exposed and unexposed areas) and normal areas using a support vector machine, which is a machine-learning method for classification. The prediction accuracy of the GC region in every area and normal region was evaluated. Additionally, the tumor thicknesses of the GC were pathologically measured, and their differences in identifiable and unidentifiable areas were compared using NIR-HSI.

Results

The average prediction accuracy of the GC regions combined with both areas was 77.2%; with exposed and unexposed areas was 79.7% and 68.5%, respectively; and with normal regions was 79.7%. Additionally, the areas identified as cancerous had a tumor thickness of > 2    mm .

Conclusions

NIR-HSI identified the GC regions with high rates. As a feature, the exposed and unexposed areas with tumor thicknesses of > 2    mm were identified using NIR-HSI.

Electro-acupuncture for health-related quality of life and symptoms in patients with gastric cancer undergoing adjuvant chemotherapy (EAGER): a protocol for a multicenter randomized controlled trial

BACKGROUND

Patients with local gastric cancer experience a decline of Health-related quality of life (HRQOL) during adjuvant chemotherapy following gastrectomy. Our previous pilot study has indicated the potential of acupuncture to improve HRQOL and control cancer-related symptoms burden. This full-scale trial will focus on confirming the effect of acupuncture for patients with gastric cancer.

METHODS

A multicenter, open-label, three-arm randomized controlled trial with 249 patients will be conducted in China. Patients will be randomly assigned, in a ratio of 1:1:1, to receive high-dose acupuncture (HA, 7 times each chemo-cycle for 3 cycles), low-dose acupuncture (LA, 3 times each chemo-cycle for 3 cycles), or no acupuncture. The acupoints prescription consisted of bilateral ST36, PC6, SP4, DU20, EX-HN3, and selected Back-shu points. Patients-reported Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) and modified Edmonton Symptom Assessment Scale (mESAS) during the therapy will be recorded. Area under curve (AUC, 21 days/cycle × 3 cycles) and average trajectory of FACT-Ga and mESAS will be calculated. The primary outcome will be the differences in AUC of the FACT-Ga Trial Outcome Index (TOI) between HA and LA versus control groups. Secondary outcomes include AUCs and average trajectory of other FACT-Ga subscales and mESAS scores.

DISCUSSION

This study aims to assess the effect of acupuncture and to compare the difference between LA and HA groups on HRQOL and symptom burden controlling in gastric cancer patients by an adequately powered trial.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of the Guangdong Provincial Hospital of Traditional Chinese Medicine (approval number: BF2018-118) with registration at ClinicalTrials.gov (identifier: NCT04360577).

A systematic review of minimal length of lroximal margin in gastric adenocarcinoma resection

For early distal gastric cancers, a proximal margin (PM) > 2-3 cm might probably be sufficient. For advanced tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

INTRODUCTION

In gastric cancer surgery, microscopic positive margin is a poor prognostic factor whereas complete resection with tumor-free margins remains a challenging issue. European guidelines recommended a macroscopic margin of 5 or even 8 cm for diffuse-type cancers to achieve R0 resection. However, it is unclear if the length of negative proximal margin (PM) could have a prognostic impact on survival. We aimed to perform a systematic review of the literature analyzing PM length and its prognostic impact in gastric adenocarcinoma.

MATERIAL AND METHODS

Pubmed and Embase databases were searched for "gastric cancer" or "gastric adenocarcinoma," combined with "proximal margin," between January 1990 and June 2021. English-written studies that specified PM length were included. Survival data, in relation to PM, were extracted.

RESULTS

Twelve retrospective studies, with a total number of 10,067 patients, met inclusion criteria and were analyzed. Mean length of proximal margin on the whole population varied from 2.6 to 5.29 cm. Three studies found minimal PM cut-off to improve overall survival in univariate analysis. Concerning recurrence-free survival analysis, only 2 series showed better results with PM > 2 or > 3 cm, using Kaplan-Meier method. Multivariate analysis demonstrated an independent impact of PM on overall survival in 2 studies.

CONCLUSION

For early distal gastric cancers, a PM > 2-3 cm might probably be sufficient. For advanced or proximal tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

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.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy

PURPOSE

This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively.

METHODS

We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5).

RESULTS

Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups.

CONCLUSIONS

L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

Comparison of Endoscopic Submucosal Dissection and Radical Surgery for Early Gastric Cancer in Remnant Stomach

(1) Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach or gastric tube is not yet widespread and few studies have compared the short-term and long-term outcomes with radical surgery. (2) Methods: A total of 73 consecutive patients with EGC in the remnant stomach or gastric tube who underwent ESD or radical surgery between October 2009 and October 2020 were retrospectively analyzed in this study. Baseline characteristics, post-operative complications, quality of life (QOL), recurrence rate, overall survival (OS) and disease-free survival (DFS) were compared between the ESD and surgery groups. (3) Results: Among the 73 patients with EGC in the remnant stomach or gastric tube, 48 (65.8%) underwent ESD and 25 (34.2%) underwent surgery. The operation time (p = 0.000) and post-operative hospital stay (p = 0.002) of the ESD group were significantly shorter than those in the surgery group. The incidence of post-operative complications in the ESD group was significantly lower than that in surgery group (p = 0.001). The ESD group had significantly better functional scale scores and lower rates of fatigue, pain, appetite loss, financial difficulties, dysphagia, eating restrictions, hair loss, and poor body image than the surgery group. There was no significant difference in OS or DFS between the ESD and surgery groups (p = 0.124 and 0.344, respectively). (4) Conclusion: ESD can significantly shorten the operation time and hospital stay, reduce surgical complications, and provide better QOL for patients with EGC in the remnant stomach or gastric tube, and its long-term prognosis is no shorter than that of radical surgery.

Extent of Surgical Resection for Gastric Cancer: The Safety Distance Between the Tumor and the Proximal Resection Margin

A potentially curative treatment scheme for gastric cancer is considered futile without a proper surgical resection. An oncological, surgical resection for gastric cancer prerequisites a proper resection of the stomach, and a D2 lymph node dissection followed by reconstruction of the gastrointestinal tract continuity. Recently, as the favorable impact of organ preserving surgery on functional outcomes has been increasingly appreciated; distal gastrectomy represents a valid alternative to total gastrectomy provided that the proper oncological principles are not violated. However, the appropriateness of distal gastrectomy as a valid type of resection becomes synonymous with achieving a negative proximal resection margin. The purpose of the present study was to assess the optimal distance between the tumor and the resection margin in a gastrectomy with curative intent, performed for gastric cancer, by reviewing the relevant literature. Having in mind, the well documented discrepancy between the gross and the pathologic boundaries of the tumor, pitfalls might be encountered. Current published guidelines have used a "safety distance" i.e., >4 or 5 cm between the proximal macroscopic tumor border and the proximal resection margin in order to guarantee a negative resection margin on pathology. An increased distance of safety is currently proposed in high-risk tumors such as tumors of the diffuse histological type.

Evaluation of postgastrectomy symptoms and daily lives of small remnant distal gastrectomy for upper-third gastric cancer using a large-scale questionnaire survey

AIM

Total gastrectomy (TG) is often performed for proximal gastric cancer. Small remnant distal gastrectomy (SRDG) can also be used in cases where surgical margins can be secured. The impact of preserving proximal small remnant stomach on postoperative quality of life (QOL) has not been fully elucidated. In the present study, we compared postgastrectomy symptoms and daily lives between patients undergoing SRDG and those undergoing TG for proximal gastric cancer using the developed Postgastrectomy Syndrome Assessment Scale (PGSAS)-45.

METHODS

Of the 1909 patients enrolled in the PGSAS NEXT study, univariate analysis of 19 main outcomes measures (MOMs) of PGSAS-45 was performed in patients undergoing TG (n = 1020) or SRDG (n = 54). Multiple regression analysis was performed with several clinical factors as explanatory variables.

RESULTS

There was no difference in age and sex between TG and SRDG groups. In SRDG group, postoperative period was shorter, the rates of laparoscopic approach and preservation of the celiac branch of the vagus nerve were higher, and the rates of clinical stage III/IV disease, ≥D2 dissection, and combined resection with other organs were lower than in the TG group significantly (P < .05). SRDG was associated with significantly lower symptoms and better daily lives than TG in 12 and 13 of 19 MOMs in PGSAS-45 by univariate and multiple regression analyses, respectively (P < .05). Several other clinical factors were also associated with certain MOMs.

CONCLUSION

The PGSAS-45 revealed that SRDG was associated with better postgastrectomy symptoms and daily lives than TG.

Impact of Surgical Margins on Overall Survival after Gastrectomy for Gastric Cancer: A Validation of Japanese Gastric Cancer Association Guidelines on a Western Series

Purpose

No consensus exists on the resection extent needed to ensure oncological safety in gastrectomy for gastric adenocarcinoma (GAC). This study aims to assess the impact of margin adequacy according to Japanese Gastric Cancer Association (JGCA) guidelines on overall survival (OS).

Patients and Methods

Patients who underwent surgery for stage I–III GAC at our institution between 2010 and 2017 were included. Margin adequacy according to JGCA, National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) guidelines was assessed, and their predictive value on OS was evaluated with Harrell’s C-index. Patients were analyzed according to their margins’ adherence to JGCA guidelines, and a propensity score matching (PSM) was run. Indication to either total gastrectomy (TG) or distal gastrectomy (DG) according to each guideline was also assessed.

Results

A total of 279 patients were included, of whom 220 (79%) underwent DG. Adequate margins according to JGCA were obtained in 209 patients (75%). On multivariate analysis, JGCA margin adequacy was independently associated with OS, together with American Society of Anesthesiologist class, neoadjuvant chemotherapy, lymphadenectomy extent, R0 resection, and postoperative N stage. After PSM, patients with JGCA adequate margins showed better OS, recurrence-free survival (RFS), and local RFS than patients with JGCA inadequate margins. For 220 DG, JGCA guidelines would have recommended TG in 25 patients (11%), NCCN in 30 (14%), and ESMO in 90 (41%) (p < 0.001).

Conclusion

Adequacy of surgical resection margins to JGCA guidelines leads to improved survival outcomes and allows for a more organ-preserving approach than Western guidelines.

Postoperative quality of life after gastrectomy in gastric cancer patients: a prospective longitudinal observation study

Purpose

The European Organization for Research and Treatment of Cancer quality of life (QOL) questionnaires (QLQ-C30, QLQ-OG25, and QLQ-STO22) are widely used for the assessment of gastric cancer patients. This study aimed to use these questionnaires to evaluate QOL in postgastrectomy patients.

Methods

We prospectively evaluated 106 patients with distal gastrectomy (DG), 57 with pylorus-preserving gastrectomy (PPG), and 117 with total gastrectomy (TG). Body weight and QOL questionnaires were evaluated preoperatively and postoperatively (at 3 weeks, and 3, 6, and 12 months).

Results

TG patients had significantly more weight loss than DG/PPG patients. Compared with DG, patients after PPG had less dyspnea (P = 0.008) and trouble with coughing (P = 0.049), but more severe symptoms of insomnia (P = 0.037) and reflux (P = 0.030) at postoperative 12 months. Compared with DG/PPG, TG was associated with worse body image, dysphagia, eating, and taste in both OG25 and STO22. Moreover, OG25 revealed worse QOL in the TG group with respect to odynophagia, eating with others, choked when swallowing, trouble talking, and weight loss. The QOL of patients who received chemotherapy was worse than those in the chemo-free group in both physical functioning and symptoms such as nausea/vomiting, appetite loss, and trouble with taste; however, these side effects would soon disappear after finishing chemotherapy.

Conclusion

PPG was similar to DG in terms of postoperative QOL and maintaining body weight, while TG was always inferior to both DG and PPG. Adjuvant chemotherapy can affect both body weight and QOL despite being reversible.

Defecation disorders are crucial sequelae that impairs the quality of life of patients after conventional gastrectomy

BACKGROUND

Defecation disorders are obscure sequelae that occurs after gastrectomy, and its implication on daily lives of patients have not been sufficiently investigated.

AIM

To examine the features of defecation disorders after gastrectomy and to explore its implication on daily lives of patients in a large cohort using the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45.

METHODS

We conducted a nationwide multi-institutional study using PGSAS-45 to examine the prevalence of postgastrectomy syndrome and its impact on daily lives of patients after various types of gastrectomy. Data were obtained from 2368 eligible patients at 52 institutions in Japan. Of these, 1777 patients who underwent total gastrectomy (TG; n = 393) or distal gastrectomy (DG; n = 1384) were examined. The severity of defecation disorder symptoms, such as diarrhea and constipation, and their correlation with other postgastrectomy symptoms were examined. The importance of defecation disorder symptoms on the living states and quality of life (QOL) of postgastrectomy patients, and those clinical factors that affect the severity of defecation disorder symptoms were evaluated using multiple regression analysis.

RESULTS

Among seven symptom subscales of PGSAS-45, the ranking of diarrhea was 4th in TG and 2nd in DG. The ranking of constipation was 5th in TG and 1st in DG. The symptoms that correlated well with diarrhea were dumping and indigestion in both TG and DG; while those with constipation were abdominal pain and meal-related distress in TG, and were meal-related distress and indigestion in DG. Among five main outcome measures (MOMs) of living status domain, constipation significantly impaired four MOMs, while diarrhea had no effect in TG. Both diarrhea and constipation impaired most of five MOMs in DG. Among six MOMs of QOL domain, diarrhea impaired one MOM, whereas constipation impaired all six MOMs in TG. Both diarrhea and constipation equally impaired all MOMs in DG. Male sex, younger age, division of the celiac branch of vagus nerve, and TG, independently worsened diarrhea, while female sex worsened constipation.

CONCLUSION

Defecation disorder symptoms, particularly constipation, impair the living status and QOL of patients after gastrectomy; therefore, we should pay attention and adequately treat these relatively modest symptoms to improve postoperative QOL.

The evaluation of the postoperative quality of life in patients undergoing radical gastrectomy for esophagogastric junction cancer using the Postgastrectomy Syndrome Assessment Scale-45: a nationwide multi-institutional study

PURPOSE

This retrospective nationwide survey investigated the quality of life (QOL) of patients with esophagogastric junction cancer after gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45.

METHODS

The Postgastrectomy Syndrome Assessment Scale-45 comprises 45 questions classified into symptoms, living status, and QOL domains. A total of 1950 gastrectomized patients with upper-third gastric or esophagogastric junction cancer returned the completed forms. Among them, 224 eligible patients with esophagogastric junction cancer were selected, including 86, 120, and 18 patients who underwent total gastrectomy, proximal gastrectomy (reconstruction-esophagogastrostomy: 56; double-tract method: 51), and other procedures, respectively.

RESULTS

The postoperative period was significantly shorter (47 ± 30 vs. 34 ± 30 months, p = 0.002), and the rates of early-stage disease and minimally invasive approaches significantly higher (both p < 0.001) in the proximal gastrectomy group than in the total gastrectomy group. Despite advantageous background factors for proximal gastrectomy, the postoperative QOL did not differ markedly between the groups. Compared to patients who underwent reconstruction with the double-tract method, patients who underwent esophagogastrostomy had significantly larger remnant stomachs but a similar QOL.

CONCLUSION

Even with total gastrectomy, a postoperative QOL comparable to that with proximal gastrectomy can be maintained. Clarifying the optimal reconstruction methods for proximal gastrectomy for esophagogastric junction cancer is warranted.

TRIAL REGISTRATION

This study was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Proximal Gastrectomy Is a Viable Alternative to Total Gastrectomy in Early Stage Proximal Gastric Cancer

Background:

Total gastrectomy with Roux-en-Y esophagojejunostomy is a life-extending procedure for patients with nonmetastatic proximal gastric and gastroesophageal junction adenocarcinoma, yet it can be a life-altering procedure with negative impact on quality of life.¹ Perioperative recovery often involves the need for supplemental nutrition (either enteral or parenteral). Furthermore, long-term effects of early satiety, dysphagia, sustained weight loss, and difficulty in maintaining a healthy weight, dumping syndrome, and intestinal overgrowth are not unusual. Although the alternative of untreated cancer is clearly unacceptable, these lifestyle consequences are not benign.

Methods:

A retrospective review of patients who had undergone laparoscopic total and proximal gastrectomy for gastric adenocarcinoma was conducted. Patient demographic data, pathologic parameters, and short-term and long-term clinical data were compared between total gastrectomy and proximal gastrectomy cohorts.

Results:

Seventeen patients were included in the study: 13 had undergone laparoscopic total gastrectomy (LTG) and 4 had undergone laparoscopic proximal gastrectomy (LPG). Patients who had LPG, given the nature of the procedure, were confined to early stage (up to T2) tumors in the gastric cardia or GE junction. Patients who had LTG tended to be larger, later stage tumors (but not exclusively). The mean operative time was greater for LTG than for LPG (247 ± 54 versus 181 ± 49 min, respectively, P = .036). Length of hospital stay (9.0 ± 3.2 versus 5.0 ± 0.8 days, P < .001) and readmission for postoperative complication (38.5 versus 0%, P = .009) were also higher in the LTG group. There was no significant difference in terms of mean estimated blood loss or blood transfusion rates, overall complications, or anastomotic stricture requiring endoscopic dilation between the patients who underwent LTG and those who underwent LPG.

Conclusion:

In early stage tumors (T1b or T2), proximal gastrectomy (PG) should be considered to mitigate diminished quality of life. PG with esophagogastrostomy, which can easily be performed minimally invasively, can be more tolerable for the patient, with no anatomic basis for dumping syndrome or small intestinal bacterial overgrowth (SIBO), and a greater reservoir for more normal meal habits when compared to total gastrectomy (TG) with Roux-en-Y reconstruction.

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.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy

PURPOSE

Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer.

MATERIALS AND METHODS

Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity.

RESULTS

The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8.

CONCLUSION

The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy

PURPOSE

Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer.

MATERIALS AND METHODS

Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity.

RESULTS

The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8.

CONCLUSION

The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Health-related quality of life after gastric cancer treatment in Brazil: Narrative review and reflections

In Brazil, gastric cancer is the third most common type of cancer among men and fifth among women, with an estimated 13360 new cases among men and 7870 among women each year during the 2020-2022 period. This study presents reflections and attempts to add knowledge to the theme of quality of life (QoL) in patients with gastric adenocarcinoma and describes some of its characteristics in three regions of Brazil, with an evaluation of the disease’s impacts in various dimensions of life, as reported by the patients themselves. We performed a narrative review of the literature and a data analysis of studies on QoL in Brazilian patients treated for gastric adenocarcinoma from three different cities in three geographic regions: Brasília (the midwest), Jaú (the southeast), and Macapá (the north).

Comparison of effects of six main gastrectomy procedures on patients' quality of life assessed by Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND

The effects of various gastrectomy procedures on the patient's quality of life (QOL) are not well understood. Thus, this nationwide multi-institutional cross-sectional study using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), a well-established questionnaire designed to clarify the severity and characteristics of the postgastrectomy syndrome, was conducted.

AIM

To compare the effects of six main gastrectomy procedures on the postoperative QOL.

METHODS

Eligible questionnaires retrieved from 2368 patients who underwent either of six gastrectomy procedures [total gastrectomy with Roux-en-Y reconstruction (TGRY; n = 393), proximal gastrectomy (PG; n = 193), distal gastrectomy with Roux-en-Y reconstruction (DGRY; n = 475), distal gastrectomy with Billroth-I reconstruction (DGBI; n = 909), pylorus-preserving gastrectomy (PPG; n = 313), and local resection of the stomach (LR; n = 85)] were analyzed. Among the 19 main outcome measures of PGSAS-45, the severity and characteristics of postgastrectomy syndrome were compared for the aforementioned six gastrectomy procedures using analysis of means.

RESULTS

TGRY and PG significantly impaired the QOL of postoperative patients. Postoperative QOL was excellent in LR (cardia and pylorus were preserved with minimal resection). In procedures removing the distal stomach, diarrhea subscale (SS) and dumping SS were less frequent in PPG than in DGBI and DGRY. However, there was no difference in the postoperative QOL between DGBI and DGRY. The most noticeable adverse effects caused by gastrectomy were meal-related distress SS, dissatisfaction at the meal, and weight loss, with significant differences among the surgical procedures.

CONCLUSION

Postoperative QOL greatly differed among six gastrectomy procedures. The severity and characteristics of postgastrectomy syndrome should be considered to select gastrectomy procedures, overcome surgical shortcomings, and enhance postoperative care.

Subtotal versus total gastrectomy for remnant gastric cancer: a systematic review and meta-analysis of observational studies

PURPOSE

Subtotal gastrectomy (SG) has become a general option for distal gastric cancer. However, the availability of an organ-preserving approach for the treatment of remnant gastric cancer (RGC) is still controversial. Thus, the objective of the present study was to assess the safety and efficacy of SG for RGC by integrating data from published articles.

METHODS

We searched the PubMed, Cochrane Library, and Web of Science databases for studies that compared SG versus total gastrectomy (TG) for RGC published from the inception of the databases until May 2020. A meta-analysis was performed using the Review Manager Version 5.0 software program from the Cochrane Collaboration.

RESULTS

Three retrospective cohort studies with 144 patients were included. The meta-analysis revealed that the operative time of the SG group was significantly shorter than that in the TG group (MD: -34.84. 95% CI: -59.97- -9.71, P = 0.007). There was no significant difference in intraoperative blood loss (MD: -109.19. 95% CI: -240.37-21.99, P =0.10), length of postoperative hospital stay (MD: 0.40. 95% CI: -3.03-3.83, P = 0.82), postoperative complications (RR: 1.41. 95% CI: 0.76-2.63, P = 0.28), or recurrence (RR: 2.33, 95% CI: 0.48-11.44, P = 0.30). SG for RGC tended to be correlated with favorable 5-year overall survival; however, the association was not statistically significant (HR: 0.89, 95% CI: 0.63-1.26, P = 0.51).

CONCLUSION

Organ-preserving approaches such as SG may be a safe and feasible treatment option for early-stage RGC.

Postprandial Asymptomatic Glycemic Fluctuations after Gastrectomy for Gastric Cancer Using Continuous Glucose Monitoring Device

Purpose

Although dumping symptoms are thought to involve postprandial glycemic changes, postprandial glycemic variability without dumping symptoms remains poorly understood due to the lack of a method that allows the easy and continuous measurement of blood glucose levels.

Materials and Methods

Patients having undergone distal gastrectomy with Billroth-I (DG-BI) or Roux-en-Y reconstruction (DG-RY), total gastrectomy with RY (TG-RY) and pylorus preserving gastrectomy (PPG) for gastric cancer 3 months to 3 years prior, diagnosed as pathological stage I or II, were prospectively enrolled from March 2018 to January 2020. The interstitial tissue glycemic levels were measured every 15 min, up to 14 days by continuous glucose monitoring. Moreover, using a diary recording the diet and symptoms, asymptomatic glucose profiles without sugar supplementation within 3 h postprandially were compared among the four procedures.

Results

A total of 40 patients were enrolled, 10 patients for each of the four procedures. There were 47 glucose profiles with DG-BI, 46 profiles with DG-RY, 38 profiles with TG-RY, and 46 profiles with PPG. PPG showed the slowest increase with a subsequent gradual decrease in glucose fluctuations, without hyperglycemia or hypoglycemia, among the four procedures. In contrast, TG-RY and DG-RY showed spike-like glycemic variability, sharp rises during meals, and rapid drops. The glucose profiles of DG-BI were milder than those of RY.

Conclusions

The asymptomatic glycemic changes after meals differ among the types of surgical procedures for gastric cancer. Given the mild glycemic fluctuations in PPG and the glucose spikes in TG-RY and DG-RY, pylorus preservation and physiological reconstruction without changes in food pathways may optimize postprandial glucose profiles after gastrectomy.

Evaluation of postoperative quality of life by PGSAS-45 following local gastrectomy based on the sentinel lymph node concept in early gastric cancer

BACKGROUND

The usefulness of sentinel node navigation surgery (SNNS) for early gastric cancer has been demonstrated in a multicenter prospective study. However, quality of life (QOL) after local resection remains unclear. This present study investigated QOL after local resection and distal gastrectomy.

METHODS

We examined 69 patients who underwent laparoscopic distal gastrectomy (LADG) (n = 44) and laparoscopic local resection (LLR) (n = 25) in our hospital between September 2011 and May 2018. We conducted a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET) with SNNS as LLR. All patients had pStage I or II and none had received adjuvant chemotherapy. We evaluated QOL using the postgastrectomy syndrome assessment scale questionnaire (PGSAS-45) 1, 6, and 12 months after surgery.

RESULTS

In PGSAS-45, no significant differences were observed between LLR and LADG at 1 and 6 months after surgery. At 12 months, the LLR group scored better for some of the subscales (SS). In the endoscopic evaluation, the LLR group showed significant improvements in residual gastritis at 6 months (P = 0.006) and esophageal reflux and residual gastritis at 12 months (P = 0.021 and P = 0.017). A significant difference was observed in the prognostic nutritional index, which was assessed using serum samples, between the two groups at 6 months (P = 0.028). The body weight ratio was better in the LLR group than in the LADG group at 6 and 12 months (P = 0.041 and P = 0.007, respectively).

CONCLUSIONS

CLEAN-NET with SNNS preserved a better QOL and nutrition status than LADG in patients with early gastric cancer.

Advantages of Distal Subtotal Gastrectomy over Total Gastrectomy in the Quality of Life of Long-Term Gastric Cancer Survivors

Purpose

This study evaluated differences and shifting patterns in the health-related quality of life (HRQoL) of 5-year gastric cancer survivors after either a distal subtotal gastrectomy (DSG) or total gastrectomy (TG).

Materials and Methods

We analyzed the prospectively collected HRQoL data of 528 patients who survived 5 years without recurrence using the European Organization for the Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC Quality of Life Questionnaire-Stomach module according to the type of surgery. The purpose was to identify the proportion of patients with deteriorating HRQoL and to assess the clinical significance of these changes.

Results

Deteriorating HRQoL was prevalent in both groups, including a large proportion of the DSG group. Decreased overall health status and scores on several function scales were less in the DSG group, while increases on the symptom scales were higher in the TG group. For most of the scales, gaps in HRQoL during the early postoperative period did not merge within the 5 years. Scores on the diarrhea and body image scales revealed "moderate changes" in both groups.

Conclusions

During the 5-year period after surgery, the TG group suffered from inferior HRQoL compared to the DSG group. However, a large proportion of the DSG group also suffered HRQoL deterioration. In general, the TG group experienced more HRQoL decline, with diarrhea and body image being the major concerns for both groups. To improve HRQoL after gastrectomy, patients must be better informed about post-gastrectomy symptoms. These symptoms must be vigorously investigated, and medical interventions should be available parallel to nutritional support. Favorable evidence of function-preserving gastrectomy should be established and disseminated to improve the HRQoL of early gastric cancer patients.

Comparison of unpalatable meal contents between patients who underwent total and distal gastrectomies

BACKGROUND

Unpalatable meal contents have several impacts on the dietary life of patients who undergo gastrectomy. However, few studies have focused on the unpalatable meal contents according to surgical procedure. This study aims to clarify the differences in the unpalatable meal contents between the patients who underwent total and distal gastrectomies (TG and DG, respectively).

METHODS

This study involved patients (n = 341) who underwent TG or DG within 5 years, and a questionnaire of unpalatable meal contents was used. The data on the demographics, operation types, Dysfunction After Upper Gastrointestinal Surgery 20 (DAUGS20) scoring system, and nutrition conditions were confirmed. Furthermore, these were analyzed using descriptive statistics and compared between TG (n = 180) and DG (n = 161) groups.

RESULTS

The unpalatable meal contents that were significantly different between two groups were big in size (p = 0.013), solid (p = 0.040), rough (p = 0.041), and dry (p = 0.045), which were more difficulty in the TG group. Furthermore, the strong sour taste was more difficulty in the DG group (p = 0.031).

DISCUSSION

The meals which the TG group had difficulty eating were characteristic of sticking or stagnating in the digestive tract, making the passage of food more difficult in the TG patients. This was because they had a smaller storage for foods and a narrower space at the anastomotic region than those who underwent DG.

CONCLUSION

The meal contents were assumed to have been influenced by the surgical procedure. We conclude that the patients in the TG group felt more difficulty in eating the meal contents that could stagnate at the anastomotic region than those in the DG group.

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.

The surgical procedure for esophagogastric junction cancer — discussing the tactics

Introduction. Currently, there is no standardized surgical tactics for the esophagogastric junction cancer treatment. The issues of the resection margin, volume of lymphodissection and the optimal size of the gastric stump are still being discussed. This article analyzes the influence of these parameters on the recurrence-free survival and postoperative quality of life for patients, according to the literature data. Objective. Analysis of the treatment outcomes for patients with esophagogastric junction cancer, depending on the surgical tactics. Materials and Methods. The article analyzes the literature data evaluating various approaches in the surgical treatment of esophagogastric junction cancer. We present an example (from the Yasuyuki Seto study) of a patient with proximal gastric adenocarcinoma with a depth of T3 invasion and the surgical tactics regarding the size of the gastric stump. a A great advantage of the resection margin located at 2 cm from the proximal margin and at 5 cm from the distal margin has been shown. According to the results of our own observations, a patient with proximal gastric adenocarcinoma with an invasion depth of T3 underwent a resection with the proximal and distal resection margins of 13 and 65 mm, respectively. Negative resection margins were diagnosed intraoperatively. The patient's recurrence -free survival was 6 years. A total gastrectomy or esophagectomy are not the operations of choice because of the worsening of the patient's quality of life. When analyzing the depth of invasion according to the literature data, it has been found that an invasion in the esophagus of more than 30 mm is associated with an increased risk of metastatic lymph nodes of the superior and middle mediastinum. With a gastric invasion length of more than 40 mm, lymph nodes of lesser curvature along the right gastric artery are affected. According to the literature, a gastric stump with the size of more than two-thirds of the organ size was favorable in terms of the postoperative quality of life. Many authors indicate the positive effect of maintaining the gastroesophageal sphincter and cardia of the stomach. In the study by Yasuyuki Seto, proximal gastric resection was applied only if it was possible to maintain more than 12 cm in the small curvature and 25 cm in the large curvature. Conclusion. When choosing the surgical tactics for the esophagogastric junction cancer, one needs to focus on the patient's quality of life after the surgery. It is necessary to achieve negative resection margins in each case. The resection margins should be more than 2 and 5 cm for the proximal and distal margins, respectively. Dissection of the lymph nodes of the middle and superior mediastinum should be carried out with invasion of the tumor into the esophagus by more than 30 mm, removal of the lymph nodes of the lesser curvature of the stomach along the right gastric artery must be carried out if the tumor invasion into stomach is more than 40 mm. It is optimal to keep the gastric stump equal to two-thirds of the size of the organ. The issue of the surgical tactics in cancer of the esophageal-gastric transition is of great practical importance and requires a further study.

Quality of life as a fundamental outcome after curative intent gastrectomy for adenocarcinoma: lessons learned from patients

Background

Gastric cancer has an important epidemiologic impact, and the main curative therapeutic modality for gastric cancer is surgical resection. However, even curative intent therapy can have negative effects on the quality of life (QoL) of these patients, which is undesirable; thus, it is difficult to balance the standardized treatment reported in the literature and treatment response to achieve full patient satisfaction. The purpose of our study was to evaluate the QoL and identify the association of scores on the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) and Short Form 36 Health Survey version 2 (SF36v2) questionnaires with sociodemographic, clinical and anatomopathological aspects of gastric adenocarcinoma patients undergoing curative surgery.

Methods

This was a cross-sectional study involving 104 patients from three regions of Brazil. Inferential analyses were used to compare (multiple regression and Mann-Whitney or Kruskal-Wallis tests) the relationships between these scores and variables (Spearman's coefficient).

Results

In the multiple regression analysis, we found correlations between Helicobacter pylori status and physical well-being (PWB) (P=0.026), between gender and emotional well-being (EWB) (P=0.008), between Lauren's histology and physical functioning (P=0.009), as well as the Short Form 36 Health Survey version 2 (SF-36v2) role-physical (P=0.027), between the tumor site and EWB (P=0.038), between the SF-36v2 mental health and N (the lower the staging, the better the score, P=0.006) and between the SF-36v2 mental health and lymph nodes removed (P=0.029). According to the Mann-Whitney or Kruskal-Wallis test, women had worse FACT-Ga total (P=0.049), PWB (P=0.005), EWB (P=0.007), gastric cancer subscale (GaCS, P=0.011), trial outcome index (TOI, P=0.030) and mental health scores than men (P=0.011). Patients with distal tumors had better scores (FACT-Ga, P=0.018; GaCS, P=0.014; TOI, P=0.020) than patients with proximal tumors. Patients with tumors located in the cardia had better physical functioning than those with proximal tumors (P=0.042). Patients who underwent partial gastrectomy had better FACT-Ga total scores (P=0.011), PWB (P=0.033), GaCS scores (P=0.006) and TOI scores (P=0.008) than those who underwent total gastrectomy. Patients who did not receive adjuvant therapy had worse bodily pain as reported on the SF-36v2 than those who received therapy (P=0.048). According to Spearman's coefficient, a higher lymph node stage corresponded to worse FACT-Ga total (s=-0.200, P=0.034), GaCS (s=-0.206, P=0.037), TOI (s=-0.216; P=0.028) and vitality (s=-0.215, P=0.029) scores. A longer time after treatment corresponded to a better SF-36v2 role-physical domain score (s=0.223; P=0.023).

Conclusions

The type of treatment instituted, postoperative time and sociodemographic and anatomopathological factors influence the QoL.

Reverse puncture device technique: an innovation of esophagojejunostomy in radical laparoscopic total gastrectomy

Aim: To evaluate the feasibility, safety, short- and long-term efficacy of a reverse puncture device (RPD) technique for esophagojejunostomy in laparoscopic-assisted total gastrectomy. Patients & methods: This retrospective study analyzed outcome data of 104 patients in propensity score matching whom were divided into the RPD and the purse-string suture technique group. Results: The RPD group had a shorter anvil placement time, shorter operative time, longer resected esophageal length, shorter incision length, shorter postoperative drainage time, shorter postoperative hospital stay and anastomotic complications than the purse-string suture technique group (p < 0.05). Multivariate analysis showed that BMI (odds ratio: 6.285, 1.446-27.322) and anvil placement time (odds ratio: 5.645, 1.089-29.321) were independent risk factors for anastomotic complications (p < 0.05). Conclusion: Laparoscopic-assisted total gastrectomy using an RPD technique is feasible, safe and effective.

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.

C-reactive protein/albumin ratio is a poor prognostic factor of esophagogastric junction and upper gastric cancer

BACKGROUND AND AIM

The C-reactive protein (CRP)/albumin (Alb) ratio has been reported as a novel prognostic marker in several cancers. The objective of this study was to investigate the prognostic value of the CRP/Alb ratio in patients who underwent surgery for adenocarcinoma of the esophagogastric junction (AEG) and upper gastric cancer (UGC).

METHODS

Data for 144 patients who underwent surgery for AEG and UGC were reviewed. The CRP/Alb ratio, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, Glasgow Prognostic Score, and controlling nutritional status score were calculated, and the relationship between these biomarkers and postoperative prognosis was analyzed.

RESULTS

The optimal cutoff value of the CRP/Alb ratio was determined to be 0.1. According to the cutoff value of CRP/Alb ratio, patients were divided into two groups (CRP/Alb < 0.1, n = 124; CRP/Alb ≥ 0.1, n = 20). The 5-year recurrence-free survival and overall survival (OS) rates were significantly lower in the patients with the CRP/Alb ratio ≥ 0.1 than in those with the CRP/Alb ratio < 0.1 (recurrence-free survival: 44.9% vs 77.9%, P = 0.0011; OS: 43.4% vs 82.0%, P < 0.0001). In the multivariate analyses, the N-stage, and CRP/Alb ratio ≥ 0.1 were identified as independent predictive factors for OS in patients with AEG and UGC (P = 0.0061 and P = 0.0439, respectively).

CONCLUSIONS

The CRP/Alb ratio was strongly associated with poor prognosis in patients who underwent surgery for AEG and UGC.

Background factors influencing postgastrectomy syndromes after various types of gastrectomy

BACKGROUND

Postgastrectomy syndromes (PGS) after curative gastrectomy for gastric cancer are influenced by not only gastrectomy type but also by background factors. Recently, a nationwide PGS study was performed using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire.

AIM

To determine the influence of each background factor on PGS for each gastrectomy type using PGS assessment study (PGSAS) data as an additional analysis.

METHODS

The data of 2368 patients were obtained from the PGSAS. This included patients undergoing distal gastrectomy (DG) with Billroth I reconstruction, DG with Roux-en-Y reconstruction, total gastrectomy with Roux-en-Y, proximal gastrectomy, pylorus-preserving gastrectomy (PPG), and local resection. Multiple regression analysis was performed to explore the independent effects of each background factor on the main outcome measures (MOMs) of PGSAS-45 for each gastrectomy type. The background factors included postoperative period, age, sex, surgical approach (laparoscopic or open), and the status of the celiac branch of the vagal nerve.

RESULTS

The MOMs of DG and PPG were highly affected by background factors, whereas those of total gastrectomy with Roux-en-Y, proximal gastrectomy, and local resection were not. Worse PGS were found in females, whereas a longer postoperative period alleviated some of the MOMs. For DG and PPG, a laparoscopic approach and preservation of the celiac branch improved several MOMs.

CONCLUSION

Various background factors affected PGS, and their influence varied with the type of gastrectomy performed. Laparoscopic surgery and celiac branch preservation can improve PGS in patients undergoing DG and PPG.