Identifying outcomes reported in exercise interventions in oesophagogastric cancer survivors: a systematic review

BACKGROUND

Research investigating exercise interventions in oesophagogastric cancer survivors is sparse, and the outcomes are varied. The aim of this systematic review is to identify the domains and outcomes reported in exercise interventions in oesophagogastric cancer survivors to be included in a Delphi study, with a view to informing the development of a core outcome set (COS).

METHODS

EMBASE, PubMed, CINHAL, Cochrane Library, SCOPUS, and PEDro were searched up to March 2020 using a predefined search strategy. The outcomes identified during data extraction were categorised using the core areas outlined in the OMERACT Filter 2.0.

RESULTS

Fourteen domains and 63 outcomes were identified. The most frequently reported outcomes were in the domains of quality of life using the EORTC-QLQ-C30 questionnaire and the relevant disease-specific modules (100%), exercise capacity/fitness/physical function (100%), anthropometrics (83.33%), physical activity (66.67%), and biomarker analysis (50%).

CONCLUSION

This systematic review quantifies and describes the domains and outcomes examined in exercise interventions in oesophagogastric cancer survivors. Some inconsistency exists within the domains and outcomes used, and little attention was given to nutritional or economic endpoints. In order to develop a COS, a Delphi consensus process with key stakeholders is needed to identify the relevant domains and outcomes for inclusion.

Rehabilitation strategies following oesophagogastric and Hepatopancreaticobiliary cancer (ReStOre II): a protocol for a randomized controlled trial

BACKGROUND

Curative treatment for upper gastrointestinal (UGI) and hepatopancreaticobiliary (HPB) cancers, involves complex surgical resection often in combination with neoadjuvant/adjuvant chemo/chemoradiotherapy. With advancing survival rates, there is an emergent cohort of UGI and HPB cancer survivors with physical and nutritional deficits, resultant from both the cancer and its treatments. Therefore, rehabilitation to counteract these impairments is required to maximise health related quality of life (HRQOL) in survivorship. The initial feasibility of a multidisciplinary rehabilitation programme for UGI survivors was established in the Rehabilitation Strategies following Oesophago-gastric Cancer (ReStOre) feasibility study and pilot randomised controlled trial (RCT). ReStOre II will now further investigate the efficacy of that programme as it applies to a wider cohort of UGI and HPB cancer survivors, namely survivors of cancer of the oesophagus, stomach, pancreas, and liver.

METHODS

The ReStOre II RCT will compare a 12-week multidisciplinary rehabilitation programme of supervised and self-managed exercise, dietary counselling, and education to standard survivorship care in a cohort of UGI and HPB cancer survivors who are > 3-months post-oesophagectomy/ gastrectomy/ pancreaticoduodenectomy, or major liver resection. One hundred twenty participants (60 per study arm) will be recruited to establish a mean increase in the primary outcome (cardiorespiratory fitness) of 3.5 ml/min/kg with 90% power, 5% significance allowing for 20% drop out. Study outcomes of physical function, body composition, nutritional status, HRQOL, and fatigue will be measured at baseline (T0), post-intervention (T1), and 3-months follow-up (T2). At 1-year follow-up (T3), HRQOL alone will be measured. The impact of ReStOre II on well-being will be examined qualitatively with focus groups/interviews (T1, T2). Bio-samples will be collected from T0-T2 to establish a national UGI and HPB cancer survivorship biobank. The cost effectiveness of ReStOre II will also be analysed.

DISCUSSION

This RCT will investigate the efficacy of a 12-week multidisciplinary rehabilitation programme for survivors of UGI and HPB cancer compared to standard survivorship care. If effective, ReStOre II will provide an exemplar model of rehabilitation for UGI and HPB cancer survivors.

TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov, registration number: NCT03958019, date registered: 21/05/2019.

The pre- and postoperative course of functional status in patients undergoing esophageal cancer surgery

INTRODUCTION

To optimally target physiotherapy treatment, knowledge of the pre- and postoperative course of functional status in patients undergoing esophagectomy is required. The aim of this prospective longitudinal study was to investigate the course of functional status in patients with esophageal cancer before and after esophagectomy.

MATERIALS AND METHODS

Functional status outcome measures of patients with esophageal cancer who underwent surgery between March 2012 and June 2016 were prospectively measured at 3 months and at 1 day before surgery and at 1 week and at 3 months after surgery. Analysis of repeated measurements with the mixed model approach was used to study changes over time.

RESULTS

Hundred fifty-five patients were measured at 3 months and at 1 day before surgery, of which 109 (70.3%) at 1 week and 60 (38.7%) at 3 months after surgery. Mean (SD) age at surgery was 63.5 years (9.3), and 122 patients (78.7%) were male. The incidence of postoperative complications was 83 (53.5%). Three months postoperatively, functional status measures returned to baseline levels, except from handgrip strength (beta [95% CI] -6.2 [-11.3 to -1.1]; P = 0.02) and fatigue (4.7 [0.7to 8.7]; P = 0.02). No differences were observed in the course of functional status between patients with and without postoperative complications.

CONCLUSION

Functional status of patients undergoing esophagectomy returned to baseline values three months after surgery, despite the high incidence of postoperative complications. This requires rethinking the concept of prehabilitation, where clearly not all patients benefit from high functional status to prevent postoperative complications.

A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol

INTRODUCTION

Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients' functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery.

METHODS AND ANALYSIS

This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal 'prehabilitation' intervention with 'standard care' in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality.

ETHICS AND DISSEMINATION

This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02950324; Pre-results.

Impact of an Early Oral Feeding Protocol on Inflammatory Cytokine Changes After Esophagectomy

BACKGROUND

The aim of the current study was to investigate the impact of early oral feeding (EOF) on inflammatory cytokine levels after McKeown minimally invasive esophagectomy (MIE) for cancer.

METHODS

This study was based on a randomized controlled trial (NCT01998230). Patients with esophageal cancer who received McKeown MIE were randomly allocated into a group that started oral feeding on postoperative day (POD) 1 (EOF group) or a second group that received nil by mouth until 7 days after operation (late oral feeding [LOF] group). We chose 86 patients, 46 patients in the EOF group and 40 patients in the LOF group, in which to analyze inflammatory cytokine levels (interleukin [IL]-6, IL-8, tumor necrosis factor-a [TNF-α], and monocyte chemotactic protein-1 [MCP-1]).

RESULTS

The EOF and LOF groups exhibited similar preoperative IL-6, IL-8 TNF-α, and MCP-1 levels. The levels of the four inflammatory cytokines at PODs 1 and 3 were significantly higher than the preoperative levels (all p < 0.001). At POD 5 the levels of all four inflammatory cytokines were decreased compared with those at PODs 1 and 3. At PODs 3 and 5 the levels of IL-6, IL-8, and TNF-α were significantly lower in the EOF group than in the LOF group (all p < 0.05). At POD 3 the MCP-1 levels in the EOF group were significantly lower than those in the LOF group (all p < 0.05).

CONCLUSIONS

Compared with conventional rehabilitation programs the EOF protocol may decrease stress response after McKeown MIE.

Pilot Prehabilitation Program for Patients With Esophageal Cancer During Neoadjuvant Therapy and Surgery

BACKGROUND

Locally advanced esophageal cancer is often treated with neoadjuvant therapy followed by surgery. Many patients present with or experience clinical deconditioning during neoadjuvant therapy. Prehabilitation programs in other areas of surgery have demonstrated improved postoperative outcomes. The aims of this study were to evaluate the feasibility of a pilot prehabilitation program and determine preliminary effects on surgical and cancer-related outcomes.

METHODS

A retrospective review of patients treated at a single institution with resectable esophageal cancer was performed (n = 22). Patients in the prehabilitation group received protocol-structured intervention in several clinical domains including nutrition, psychosocial support, and physical exercise.

RESULTS

Clinical stage and comorbidities were well matched between groups. The structured prehabilitation program was feasible and well received by participants. Fewer patients required admission during neoadjuvant therapy in the prehabilitation group (27.3% versus 54.5%). Percentage weight loss during treatment was 3.0% in the prehabilitation group versus 4.3% in the control group. Compared with the control group, the prehabilitation group demonstrated 0.0% versus 18.2% 30-d postoperative readmission rate and 18.2% versus 27.3% 90-d postoperative readmission rate. There were no statistically significant differences between groups in regard to complications or mortality.

CONCLUSIONS

The pilot prehabilitation program demonstrated feasibility of implementing a structured program for patients receiving neoadjuvant therapy for esophageal cancer. Although the small population limits evaluation of statistical significance, trends in the data suggest a potential benefit of the prehabilitation program on neoadjuvant hospital admission rates, postsurgical readmission rates, and nutritional status.

[Relationship between Nutritional Biochemical Parameters and Body Weight Loss in Patients with Esophageal Cancer Up to One Year after Surgery]

SUBJECTS AND METHODS

The subjects comprised 21 patients with esophageal cancer who underwent surgery, without adjuvant chemotherapy. Caloric intake, body weight loss, and biochemical parameters(serum albumin[Alb], hemoglobin[Hb], transthyretin[TTR], and total cholesterol[T-Cho])were measured up to 1 year after surgery, and relationships between all parameters were investigated.

RESULTS

The caloric intake dropped to about 87% of base-line intake at 1 month after surgery and recovered to 100% at 1 year after the operation. Body weight also dropped to about 89% of baseline at 6 months after surgery and then was relatively stable. Caloric intake was significantly positively correlated with TTR(r=0.82, p=0.02), and it also tended to be positively correlated with T-Cho(r=0.70, p=0.14). Body weight loss was significantly negatively correlated with Alb(r=-0.82, p=0.01)and Hb(r=-0.87, p=0.01).

CONCLUSION

Alb and Hb were recovered in the early postoperative period when body weight was still decreased. However, TTR appeared to be a good parameter of caloric intake in the short-term, postoperatively.

[Strategy and prospective of enhanced recovery after surgery for esophageal cancer]

Enhanced recovery after surgery (ERAS) is a patient-centered, surgeon-led system combining anesthesia, nursing, nutrition and psychology. It aims to minimize surgical stress and maintain physiological function in perioperative care, thereby expediting recovery. ERAS theory has been clinically applied for nearly 20 years and it is firstly used in colorectal surgery, then widely used in other surgical fields. However, ERAS is not used commonly in esophagectomy because of its surgical complexity and high morbidity of postoperative complications, which limits the application of ERAS in the field of esophagectomy. In recent years, with the increasing maturation of minimally invasive esophagectomy, attention to tissue and organ protection concept, improvement of making gastric tube, breakthrough of anastomosis technique, and the presentation and application of new concepts, ERAS has made great progress in the field of esophagectomy. This article summarizes some ERAS measures in the treatment of esophageal cancer based on evidence-based medicine, and performs an effective ERAS mode for clinical application of esophagectomy. During preoperative preparation and evaluation, we propose preoperative education and nutrition evaluation without regular intestinal preparation, and advocate preemptive analgesia without preanesthetic medication. During intra-operative management, anesthesia scheme should be optimized, fluid transfusion should be controlled properly, suitable operation mode should be chosen, and intraoperative hypothermia should be avoided. During postoperative management, sufficient analgesia should be administered with non-opioid analgesics, drainage tube placement must be decreased and removed earlier, urinary catheter and gastrointestinal decompression tube should be removed earlier, and oral intake and ambulation should be resumed as early as possible. "Received surgery yesterday, oral intake today, discharged home 5-7 days", ERAS program based on "non tube no fasting" has been applied in some medical centers and becomes more and more maturation. In the future, we will rely on the increasing improvement and systemic training of ERAS mode in order to promote such application in more medical centers. With the multi-center clinical trials, based on constant enrichments and improvements, a general expert consensus will be made finally.

Burden of spousal caregivers of stage II and III esophageal cancer survivors 3 years after treatment with curative intent

OBJECTIVES

The aim of this study is to examine caregiver burden of spousal caregivers of patients with esophageal cancer after curative treatment with neoadjuvant chemoradiation followed by resection and to assess factors associated with caregiver burden.

METHODS

In this exploratory, cross-sectional study, spousal caregivers and patients were eligible if the caregiver was the patient's spouse and the patient had been treated with chemoradiation followed by surgery after esophageal carcinoma diagnosis. Forty-seven couples were included. Spousal caregivers completed a questionnaire, examining caregivers' burden (Self-Perceived Pressure from Informal Care (SPPIC, Dutch)), caregiver unmet needs (SCNS-P&S), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), and marital satisfaction (Maudsley Marital Questionnaire (MMQ)). Patients completed the latter two questionnaires and a cancer specific quality of life questionnaire (EORTC-QLQ C30 and OES18 (oesophageal module). Logistic regression analysis was performed to identify correlates for caregiver burden.

RESULTS

The median time after esophagectomy was 38 months. Thirty-four percent of the spousal caregivers reported moderate or high burden. Spousal caregivers most frequently reported unmet needs were managing concerns about the cancer coming back (43%), dealing with others not acknowledging the impact on your life of caring for a person with cancer (38%), and balancing the needs of the person with cancer and one's own needs. A comparable proportion of spousal caregivers and patients showed symptoms of anxiety (23 vs 17%) and depression (17 vs 17%). Spousal caregivers reported significantly more dissatisfaction than patients on the marital scale (p < 0.01). Factors independently associated with higher caregiver burden were fatigue of the patient (OR = 1.66, 95% CI 1.12-2.47) and depression of the spousal caregiver (OR = 1.44, 95% CI 1.11-1.86).

CONCLUSIONS

More than a third of the spousal caregivers of patients with esophageal cancer treated with curative intent report moderate or high burden 3 years after treatment. Fatigue of the patient and depression of the spousal caregiver are associated with caregiver burden. To improve clinical care, identification of spousal caregivers at risk for experiencing higher caregiver burden and implementation of specific interventions is needed.

The threshold moment: ethical tensions surrounding decision making on tracheostomy for patients in the intensive care unit

With the aging of the general population and the ability of intensivists to support patients using ventilator support, tracheostomy has become a vital tool in the medical management of critically ill patients. While much of the medical literature on tracheostomy has focused on the optimal timing of and indications for performing this procedure, little is written on the ethical tensions that can revolve around decisions by patients, surrogates, and physicians on its use.This article will elucidate the ethical dilemmas that can arise surrounding the use of tracheostomy in critically ill patients and how ethics consultants and committees can approach these cases to allow resolution.

Remapping the body: learning to eat again after surgery for esophageal cancer

Surgery for esophageal cancer offers the hope of cure but might impair quality of life. The operation removes tumors obstructing the esophagus but frequently leaves patients with eating difficulties, leading to weight loss. Maintaining or increasing body weight is important to many patients, both as a means of returning to "normal" and as a means of rejecting the identity of the terminal cancer patient, but surgery radically alters embodied sensations of hunger, satiety, swallowing, taste, and smell, rendering the previously taken-for-granted experience of eating unfamiliar and alien. Successful recovery depends on patients' learning how to eat again. This entails familiarization with physiological changes but also coming to terms with the social consequences of spoiled identity. The authors report findings from in-depth interviews with 11 esophageal cancer patients, documenting their experiences as they struggle to achieve a process of adaptation that is at once physiological, psychological, and social.

Oesophageal cancer: Experiences of patients and their partners

Oesophageal cancer (OC) is a debilitating disease with significant social, psychological and physical impacts on health and lifestyle (Mills and Sullivan, 2000). The research presented in this paper uses a survey method, and reveals that patients require honest communication and more help with everyday living from nurses to facilitate recovery. Each patient is unique but commonalities can be established that improve experience and outcome. Three themes emerged from the data: food, activity and positivity. To meet long-term needs, the Oesophageal Patients Association is fundamental for patients and carers in order adapt to this major life-changing event.

Implications for case management: ensuring access and delivery of quality health care to undocumented immigrant populations

Immigrants are an integral part of the history and diversity of the United States. Now more than ever, this growing population is facing a major challenge related to the widening gap in overall healthcare access and health insurance coverage. This gap raises concerns related to access, economics, fear of detection, and cultural/language barriers to care, which extend beyond the individual person to affect the community at large. This is particularly true for those immigrants who are residing in this country illegally. Healthcare providers, in general and hospitals in particular, face many challenges in providing care to this group. As the immigrant population continues to grow, the case management community will face an ongoing challenge to expand and refine its knowledge base and incorporate key competencies into its practice patterns in order to ensure access to and delivery of healthcare to this largely underserved group. This article specifically addresses the undocumented population, and identifies opportunities to encourage and promote access to healthcare while providing effective care management interventions.

Rehabilitation and quality of life in patients undergoing surgery for esophageal cancer

The impact of esophageal cancer surgery, postoperatively as well as on quality of life (QoL) is still largely unknown. Clinical experience and the scarce existing literature concur that these patients show difficulty in returning to their original lifestyles and previous social activities, not just due to the difficulties common to all tumor pathologies but also for the specific dietary and digestive disturbances which characterize esophageal cancer therapy. As specific rehabilitation protocols are nonexistent in the literature, in this study a rehabilitation planning program, is proposed based on evaluation of postoperative and long-term problems which can be tackled with rehabilitation.

Rehabilitation in esophageal cancer

Cancer of the esophagus has an unfavorable prognosis with a five-year survival rate after radical surgery of less than 10%; early diagnosis is difficult. The appearance of symptoms, particulary dysphagia, is due to more than 2/3 tumor involvement of the esophageal circumference, already present in 2/3 of patients at diagnosis. Symptoms can be local and/or systemic; they can be physical, psychic, iatrogenic and evolutive. A careful rehabilitation program should follow these patients during the entire course of their disease The rehabilitation approach intends to define areas of intervention, short-term goals, possible achievements, role of health operators and overall verifications. Common problems of patients with esophageal cancer, are analyzed. A rehabilitation program including the patient care throughout the hospitalization period to improve his/her autonomy with respect to his/her social and familial activities, is illustrated.

[Visceral voice training for laryngectomy after hypopharyngectomy and visceral transplant]

OBJECTIVE

To establish a way to visceral voice after stomach or colon transplantation for patients with hypopharyngeal or cervical esophageal cancer.

METHODS

Esophageal voice training was used and modified according to the compliance of the patients. Twenty laryngectomies with replacement of the hypopharynx and esophagus by stomach(13 cases), colon(6 cases) and jejunum (1 case) were trained for voice rehabilitation at the Department of Head and Neck Surgery.

RESULTS

The patients with an artificial esophagus from vicera were easy to gain an influx of certain volume of gas into their artificial esophagus (stomach or colon) and to learn to speak. But on the whole the quality of voice was not so satisfactory. In this series nineteen out of 20 patients (95%) could express their idea by speech after a training course of three weeks.

CONCLUSION

The literature has emphasized role of cricopharyngeus muscle in the training of esophageal voice. Owing to the fact that this series of patients who had had their cricopharyngeus removed, could easily get their voice rehabilitated, it seems this muscle played no major role in the voice rehabilitation.

[Quality of life assessment in radiation therapy]

Cancer treatment outcome should be evaluated not only with conventional parameters of survival, local control, and response rate, but with quality-of-life (QOL) based parameters. As radiation therapy is a treatment to eradicate cancer without resection of tissues or organs, a better functional or cosmetic result could be obtained compared with surgical treatment. If basically functional or cosmetic results are better, QOL of the patient could be expected to be even more superior. Patient QOL should be assessed from the physical, psychological, and social standpoints. So, adequate instruments or scoring systems are essential to obtain data. In this paper, we introduce an outline of QOL-related research activities in cancer treatment, especially in radiation therapy. We also attempt to assess the functional outcome and late complications, which would affect patient QOL. Finally, the concept of quality adjusted survival time or utility analysis is also mentioned.

[Pulmonary function during exercise before and after radical esophagectomy for esophageal cancer]

Since the postoperative long-term evaluation for thoracic esophageal carcinoma had not been sufficient by a conventional respiratory function test alone, investigation was carried out by observing the changes in motor tolerance. The subjects were selected of 50 cases who elapsed more than 3 months before and after the operation among the cases who had been undergone radical operations with right thoracotomy and laparotomy for thoracic esophageal carcinoma; and then all of the subjects were subjected to a conventional respiratory function test and a respiratory movement loading test. Furthermore, investigation by use of multivariate analysis (Quantification: Class 1) was conducted for the factors relating to the depression of respiratory movement. For loading the movement, bicycle-type ergometer were employed, and a graded gradual-increase loading method was adopted. With the general respiratory function test, vital capacity was depressed from a preoperative average value of 2.1 +/- 0.4 (1/m2) to a postoperative average value of 1.6 +/- 0.3 (1/m2) showing a depressing trend being significant to a postoperative condition (p < 0.0001), and no significant postoperative difference was observed for FEV 1.0%. Even in such a condition, no significant depression was observed for oxygen intake at resting, but the maximum oxygen intake showed a significant depression (p < 0.0001) from a preoperative average value of 22.3 +/- 5.0 to a postoperative average value of 19.3 +/- 4.1 ml/min/kg. The maximum carbon oxide evacuation showed a significant depression (p < 0.0001) after operation. The ventilation quantity in a course of movement showed a depressing trend after operation, with be number of respiration in an increasing trend, showing a shallow-but-quick respiratory pattern. Mobility restriction due to circulation factors was not observed, and also the nutrition before and after operation did not show any significant difference in the blood examination. But the lactic acid during movement showed a significant increase after operation. As described above, it is considered that a pattern of restrictive impairment at resting increased an oxygen equivalent resulted from depression of oxygen intake by the movement, an increase in dead space ventilation rate for minute ventilation at movement, and a shallow-but-quick respiratory pattern have caused aggravation of the ventilation efficiency, which finally led to the interruption of movement. In a long-term period, as clinical factors relating to those, cigarette smoking, nutrition before operation, age, and postoperative radiation therapy are concerned, which were thus considered the key factors in considering the postoperative long-term QOL. Nutrition and rehabilitation by continuous muscle training is necessary to improve the long-term QOL, after radical esophagectomy.

Development of an EORTC questionnaire module to be used in quality of life assessment for patients with oesophageal cancer. The EORTC Quality of Life Study Group

Quality of life (QOL) assessments in patients with oesophageal cancer should provide clinically meaningful data that can assist management decision making. This study describes the development of a specific module for oesophageal cancer to use with the European Organisation into Research and Treatment of Cancer (EORTC) QOL questionnaire, the EORTC QLQ-C30. Relevant QOL issues were generated from a literature search and interviews with patients and oesophageal cancer specialists. Issues were formulated into items compatible with those of the EORTC QLQ-C30. The provisional module was pretested in patients from the United Kingdom, Spain and Sweden. The resulting module, the QLQ-OES 24, includes 24 items conceptualised as containing six scales and five single items. The addition of an oesophageal cancer-specific module to the core questionnaire should improve the sensitivity and specificity of the core instrument to allow detection of even small benefits accrued from new treatment modalities.

[The efficacy of pyloroplasty affecting to oral-intake quality of life using reconstruction with gastric tube post esophagectomy]

After resection of esophageal carcinoma, pyloroplasty was undergone due to vagal denervation. Especially the ability of oral-taking is related to the return of general societies after operation. This was a randomized study on whether pyloroplasty was effective by functional and nutritional evaluations. From 1992 to 1995, 67 patients with esophageal carcinoma underwent subtotal esophagectomy and reconstruction using a gastric tube. Thirty-four patients were randomized into the pyloroplasty group (P), and 33 into the control group (N). The functional evaluation was done with (1) food-taking scoring (2) A foods with barium granules ejection time (3) a gastric emptying time of 99m Technecium (4) 75 g OGTT. The nutritional evaluation were (1) Rapid Turn-over Protein (RTP) (2) Total Lymphocyte Count (TLC) (3) ONODERA's Prognostic Nutritional Count (PNI) (4) Fluctuation rate of body weight. The elevations were performed 1 and 6 months after operation. Functional evaluation were as follows. (1) Quantity of oral-intake was not significant different between (P) and (N) both improving those quantities in 6 months. Regarding several complaints including in regurgitation, (P) had a few symptoms comparing to (N), almost half of cases complained of some symptoms and did not improving in 6 months. (2) The food ejection time of foods were 19.6 +/- 31.0 min, in (P), 32.9 +/- 37.2 min, in (N), (3) In the Tc gastric emptying time, we calculated as 50% ejecting time and residual rate of 30 min. In 50% ejecting time less than 20 min., (P) shared in 65, 80%, (N) in 39, 40% in 1 and 6 months. (4) In 75 g OGTT there were no significant difference between both groups, though several cases showed the dumping syndrome. In the nutritional evaluation, in RTP, TLC, PNI, and postope, body weight, there were no differences between the two groups. In conclusion, pyloroplasty several symptoms related to oral intake including regurgitation feelings, and in functional evaluation, there shows faster gastric emptying though there were no significant differences in the nutritional phases at 6 months follow-up. The results suggest that this procedure is not essential but it affects to the oral-intake QOL effectively.

Quality of life of patients with oesophageal carcinoma

'Quality of life' is a concept of central importance in oncology nursing. This paper discusses a nurse-led audit of the quality of life experienced by patients with oesophageal cancer, and what is hoped to be achieved by it.

Gastric pull-up reconstruction for pharyngo-laryngo-esophagectomy

OBJECTIVE

To determine the results of gastric pull-up reconstruction following pharyngo-laryngo-esophagectomy.

DESIGN

Retrospective review of 59 patients who underwent gastric pull-up reconstruction for carcinoma of the hypopharynx, larynx, and cervical esophagus during a 10-year period from 1983 to 1993.

SETTING

Combined Head and Neck Service and Section of General Surgery, Department of Surgery, Yale University Medical School, New Haven, Conn.

MAIN OUTCOME MEASURES

Morbidity, mortality, time to oral feeding, length of hospitalization, and long-term results.

RESULTS

The mortality rate was 5%, perioperative morbidity rate, 27%, and the medical morbidity rate, 32%. Most patients took oral feedings within 6 days after surgery and were discharged within 16 days. There were two temporary fistulas and four strictures, none of which were permanent. There were no intrathoracic or mediastinal injuries or hemorrhage. The overall survival was 1 to 100 months (median survival, 12 months); the median survival was 34 months for patients alive to date and 8 months for patients who died.

CONCLUSIONS

The gastric pull-up reconstruction is a safe, effective operation with a low mortality rate and excellent long-term functional results for patients with extensive carcinoma of the hypopharynx, larynx, and cervical esophagus.

Intraoperative radiotherapy for esophageal carcinoma--significance of IORT dose for the incidence of fatal tracheal complication

PURPOSE

The feasibility of intraoperative radiotherapy (IORT) combined with modified regional lymphatic dissection (plus esophagectomy) for advanced esophageal carcinoma was tested. The quality of life in the patients was expected to improve by modified surgery, securing a good local control by additional IORT.

METHODS AND MATERIALS

Total esophagectomy plus modified three-regional lymphatic dissection with upper mediastinal IORT followed by postoperative external beam irradiation was systematically given to 62 patients between August 1989 and June 1992. Sixty-five percent of the patients were age over 60, and 76% (47/62) of the patients were Stage III or IV by pTNM. Several techniques for the IORT were developed and used throughout this period, including a temporary collapse of the right lung by unilateral tracheal incubation (for the insertion of IORT applicator) and an in vivo dosimetry to know the appropriate range (energy) of electron beam. The method of surgical treatment, the dose of external beam irradiation were kept standardized, and only the dose of IORT was randomized either to 20 or 25 Gy. IORT-related complications and the pattern of failures were carefully monitored.

RESULTS

(a) Most prominent IORT-related complication was the late tracheal damage, which occurred 6 of 44 patients who were at risk for more than a year. (b) The incidence of IORT-induced tracheal damage was sharply dependent on the dose of IORT; 6 out of 21 patients who received single dose of 25 Gy, and none out of 33 who were given 20 Gy or less. (c) 2-year cause-specific survival and actuarial 2-year survival were 75.0 +/- 14.5% and 62.5 +/- 13.2%, respectively. No loco-regional recurrence has been detected at the time of analysis.

CONCLUSION

IORT in combination with modified total esophagectomy is an effective and safe method to obtain a local control in advanced esophageal carcinomas, if the dose of IORT does not exceed 20 Gy.

[Subjective discomfort of stomach cancer and esophageal cancer patients in after-care]

In the framework of a study on the rehabilitation needs in gastric and oesophageal cancer patients, 100 gastric and 100 oesophageal cancer patients were interviewed on their subjective emotional state and physical functioning. The potentially cured patients were admitted to our in-patient aftercare programme an average 9.5 months following primary treatment. Major psychological distress was reported by 69.5% of the patients. Brooding, unrest, nervousness, and insomnia were the most frequently named complaints in both groups. 93% reported physical limitations, and 80% felt their conditions of life more or less restricted by their disease. 50% of all patients reported lack of drive, 30% an inclination to withdraw and a basic attitude of resignation. No significant differences between gastric and oesophageal cancer patients were found concerning type and frequency of the complaint.

[Multidisciplinary treatment principles for improved QOL in patients with esophageal cancer]

We recently performed multidisciplinary treatment for improved QOL in patients with esophageal cancer according the following principles: 1. The expected preoperative diagnosis of staging for esophageal cancer is performed by preoperative examinations, and the plan for perioperative combined therapy is established. 2. For intraepithelial cancer (ep) and lamina propria mucosal cancer (mm), small stress treatment is the choice. For submucosal cancer (sm), esophagectomy with right thoracotomy and lymph node dissection are performed as a rule, but where negative lymph node metastasis is inferred by preoperative examination, esophagectomy without thoracotomy (blunt dissection) and postoperative adjuvant therapy are performed. 3. For advanced esophageal cancer, adjuvant therapy is performed as far as possible in consideration of depth of invasion, lymph node metastasis and general condition. 4. For far advanced esophageal cancer, esophageal prosthesis intubation is the first choice, and adjuvant therapy is performed in patients with a relatively fair general condition.

Quality of Life in patients with resected oesophageal cancer

Quality of Life (QL) is hard to assess and seldom measured in patients having carcinomas with an unfavourable prognosis. Oesophageal cancer is one of the malignancies with a low 5-year survival rate. Dysphagia (problems in swallowing food) is considered to be the most important indicator of QL in patients with oesophageal carcinoma. Moreover, the psycho-social aspects and subjective QL in cancer have recently gained importance. The present study investigated QL in a 132 patients with oesophageal cancer. Eighty-three of them had a surgical operation (removal of part of the oesophagus and part of the stomach, followed by a reconstruction of the digestive tract). Sixty-seven patients filled in questionnaires before and after the operation. Complete sets of data were obtained from 62 patients. Time interval between operation and postoperative assessment varied from 3 to 7 months. Indicators of QL were: Psychological Distress, Physical Symptoms, Global Evaluations, Activity Level, Swallowing Problems and Food Intake. Swallowing Problems showed moderate correlations with the other QL indicators. Physical Symptoms increased, whereas the Activity Level, Psychological Distress, and Swallowing Problems decreased; Global Evaluations remained unaltered.

[Quality of life of patients after esophagectomy for esophageal cancer]

Quality of life of 79 patients who underwent esophagectomy for esophageal cancer and survived more than one year was evaluated by a questionnaire method. About 90% of patients had a good appetite, taking ordinary solid foods, and 69% were satisfied with the daily amount of foods. About 40% of patients complained of passage disturbance on swallowing, abdominal pain or diarrhea after meal. Fifty seven per cent of patients had frequent episodes of cough and sputum, and 20% were not able to go up the stairs to the third floor because of short breath. Thirty two per cent of patients with recurrent nerve paresis and even 5% without paresis had a trouble in daily conversation. These physical distresses were thought to be useful indicators for the doctor to evaluate the quality of life of patients. Additionally, about 30% of patients had a tendency of mental depression postoperatively. Fifty six per cent of patients who had worked before operation returned to work or were doing a lighter work than before. The psychological factor and social rehabilitation were suggested to be very important, when evaluated from the patient's side. Especially in case of aggressive surgery for esophageal cancer, postoperative quality of life of patients should be carefully considered from the viewpoints of both the patient and doctor.

[Reconstruction of the cervical part of the esophagus using a free revascularized segment of the jejunum and microsurgical technic]

The article analyses the experience in 11 reconstructions of the pharynx and cervical esophagus with a free vascularized jejunal segment employing microsurgical technique for squamous cell carcinoma of the upper digestive tract. The operative technique is described. It is noted that this operative procedure is a difficult method of surgical management of defects in the pharynx and cervical esophagus and is attended in some cases with complications. From personal experience and review of the literature, the authors conclude that autotransplantation of a free vascularized jejunal segment with the use of microsurgical technique is the best method for reconstruction of defects in the pharynx and cervical esophagus.

[Plastic surgery of the cervical segment of the esophagus using free autologous transplant of a fragment of the small intestine]

The article presents an experience with the treatment of patients with malignancy of the larynx, laryngopharynx and cervical part of the esophagus with a free autotransplant of the small intestine using a microsurgical technique for reestablishment of the arterial and venous blood circulation in the transplant. On the basis of the postmortem material the advantage of using the initial part of the jejunum were revealed. Experimental studies for the development of the microsurgery technique allowed the authors to propose some methodical means specially for the above operations. Eight operations were performed in the clinic with good functional results.

[Surgical treatment of esophageal cancer and gastric cancer in relation to a questionnaire on the daily lives of the patients]

A questionnaire on the daily life was mailed to patients who had undergone esophagectomy and retrosternal esophagogastrostomy. Replies came from 29 patients. Employment of the patients was 66%. However 97% of the patients could go out and enjoy their own ordinary lives. Replies of questionnaires came from 66 patients aged 70 and over who had undergone gastrectomy. Employment of the patients who had worked before operation, was decreased, 60%. However, 88% of the patients could go out and enjoy their own ordinary lives.

Rehabilitation problems after pharyngogastric anastomosis

Fifty-three patients had pharyngolaryngoesophagectomy during the years 1965 to 1976 for lower hypopharyngeal or cervical esophageal cancer. The operative mortality--defined as the percent of patients who died within seven days of operation--was 7.5%, which is reduced to 5.6% if one patient with inoperable disease is excluded. Twenty-eight percent of patients survived for longer than one year, and there have been no problems with swallowing. Communication is possible in every patient who possesses good motivation, but the problems of long-term management of calcium metabolism still require attention.