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

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.

Comparison of proximal gastrectomy and total gastrectomy in proximal gastric cancer: a meta-analysis of postoperative health condition using the PGSAS-45

PURPOSE

Proximal gastrectomy (PG) offers advantages over total gastrectomy (TG) in enhancing the postoperative nutritional status of patients with proximal gastric cancer (PGC), yet its effect on long-term quality of life is still debated. This study aims to thoroughly compare postoperative health condition outcomes between PG and TG.

METHODS

We conducted a systematic search of English-language articles from the PubMed, Web of Science, and Cochrane Library databases, covering studies published up to February 2023. Key evaluation endpoints included surgical outcomes and postoperative health condition, assessed using the Post-Gastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

RESULTS

Six retrospective cohort studies were included in the analysis. The PG group demonstrated no significant negative impact on surgical outcomes compared to the TG group. Notably, patients who underwent PG experienced a superior postoperative health condition, characterized by fewer gastroesophageal reflux symptoms (WMD = -0.106, 95% CI -0.183 to -0.029, P < 0.01), less weight loss (WMD = 4.440, 95% CI 3.900 to 4.979, P < 0.01), and reduced dietary dissatisfaction (WMD = -0.205, 95% CI -0.385 to -0.025, P = 0.03).

CONCLUSION

This study provides compelling evidence that PG is superior to TG in enhancing postoperative health condition for patients with proximal gastric cancer, without compromising surgical outcomes. However, further rigorous randomized controlled trials are necessary to inform surgical decision-making more effectively.

Oncological relevance of proximal gastrectomy in advanced gastric cancer of upper third of the stomach

Background

The oncological relevance of proximal gastrectomy in advanced gastric cancer remains unclear. We aimed to examine the frequency of lymph node metastasis in advanced gastric cancer to determine the oncological validity of proximal gastrectomy selection.

Materials and methods

This study included consecutive 71 patients with locally advanced gastric cancer in the upper third of the stomach who underwent total gastrectomy at our institution between 2001 and 2017. Lymph node metastasis and its therapeutic value index were examined to identify candidates for proximal gastrectomy. Metastatic and 3-year overall survival rates of numbers 3a and 3b lymph nodes were examined from 2010 to 2019.

Results

The metastatic rate and therapeutic value index of numbers 4d, 5, 6, and 12a lymph nodes were zero or low. The number 3 lymph node had a metastatic rate and therapeutic value index of 36.6 % and 31.1, respectively. The metastatic and 3-year overall survival rates of the number 3a lymph node were 32.7 % and 89 %, respectively, whereas those of the number 3b lymph node were 3.8 % and 100 %, respectively. All patients with positive metastasis to the number 3b lymph node received adjuvant chemotherapy. Histopathological findings of positive metastasis to the number 3b lymph node were located in the lesser curvature, and the tumor diameter exceeded 40 mm.

Conclusion

For advanced gastric cancer of the upper third of the stomach, the indications of localization to the lesser curvature and a tumor diameter of >40 mm should be considered cautiously.

A comparison of the effects of anti-reflux procedures during esophagogastrostomy after proximal gastrectomy on the postoperative quality of life

PURPOSE

To investigate the postoperative quality of life (QOL) in patients with proximal gastric cancer (PGC) or esophago-gastric junction cancer, a nationwide multi-institutional study (PGSAS NEXT trial) was conducted.

METHODS

Patients who had undergone radical resection more than 6 months previously were enrolled from 70 Japanese institutions between July 2018 and June 2020. The Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 questionnaire was distributed to eligible patients, and responses were collected by mail. The main outcome measures of the PGSAS-45 were then calculated and compared.

RESULTS

Questionnaires were retrieved from 1950 participants, and data from 300 patients who had undergone a proximal gastrectomy (PG) with esophagogastrostomy for PGC were analyzed. The mean esophageal reflux subscale value was 1.9 among the 276 patients who underwent an anti-reflux procedure, which was significantly better than the mean value (2.6) for the 21 patients who did not undergo an anti-reflux procedure (p = 0.002). The esophageal reflux subscale values were also compared among 3 major anti-reflux procedures: the double-flap technique (N = 153), the pseudo-fornix and/or His angle formation (N = 67), and fundoplication (N = 44); no statistically significant differences were observed.

CONCLUSION

An anti-reflux procedure during esophagogastrostomy after PG for PGC is necessary to improve postoperative esophageal reflux symptoms, regardless of the type of procedure.

TRIAL REGISTRATION

The PGSAS NEXT study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction

PURPOSE

Despite the increasing incidence of adenocarcinoma of the esophagogastric junction, laparoscopic proximal gastrectomy with lower esophagectomy (PGLE) is not widely accepted owing to the lack of standardized reconstruction techniques. In this study, we developed a new reconstruction method named y-shaped overlap esophagogastric tube reconstruction, which reproduces an angle of His and a pseudo-fornix, to be used in laparoscopic transhiatal PGLE. This study aimed to determine the feasibility of this novel reconstruction method.

METHODS

This retrospective study included the analysis of short- and mid-term surgical outcomes of 30 consecutive patients with Siewert type II esophagogastric junction adenocarcinoma who underwent laparoscopic PGLE with y-shaped overlap esophagogastric tube reconstruction from April 2015 to August 2020. A novel method was used to form a 6-cm pseudo-fornix and an angle of His using the distal esophagus and a long gastric tube.

RESULTS

The median operation time was 369 min, and the median blood loss was 28 mL. The median follow-up period after surgery was 37 months. Although two patients experienced postoperative anastomotic leakage, none of the patients developed stenosis. One patient experienced moderate reflux symptoms, whereas four patients developed moderate reflux esophagitis based on the 1-year follow-up endoscopic examination; the condition of all patients could be efficiently controlled with medication.

CONCLUSION

The short- and mid-term surgical outcomes of y-shaped overlap esophagogastric tube reconstruction reflected the feasibility of this simple technique and suggested its potential utility as a reconstruction alternative for Siewert type II tumors.