Development and validation of a symptom scale to evaluate postoperative patients with esophagogastric cancer

Nutrient Intakes and Gastrointestinal Symptoms Among Esophagogastric Cancer Survivors up to 5 Years Post-Surgery

A cross-sectional analysis explored nutritional intakes and gastrointestinal (GI) symptoms among esophagogastric cancer survivors up to 12, 13-36, and 37+ months post-surgery. Participants were identified from the Upper GI Cancer Registry at St James' Hospital, Ireland. The Short Nutritional Assessment Questionnaire, European Prospective Investigation of Cancer Food Frequency Questionnaire, World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Score, and Gastrointestinal Symptoms Rating Scale assessed malnutrition risk, nutritional intake, adherence to (secondary) cancer prevention recommendations, and GI symptoms, respectively. Most (82.5%, n33) participants (n40) were male. Mean age was 65.5 ± 9.3 years. Time post-surgery ranged from 6-62 months. Half (50.0%, n20) had a BMI in the healthy range. A quarter (27.5%, n11) were at risk of malnutrition. Intakes of meat and meat products exceeded recommendations and intakes of fruits, vegetables, and fiber were below recommendations, with no significant between-group differences. The mean WCRF/AICR score was 3.6 ± 1.1, indicating adherence to 3.6 of 7 cancer prevention recommendations. It was not significantly different between subgroups. Minor to mild GI discomfort was reported, with no significant between-group differences in symptoms. As rates of long-term survivorship continue to increase, survivors must be supported to sustain behaviors that enhance quality of life and reduce secondary cancer risk.

Development of a conceptual framework to detect perioperative symptom burden following abdominal surgery for cancer

BACKGROUND

Abdominal surgery for gastrointestinal malignancies has a significant impact on patients' health-related quality of life. However, there is so far no patient-reported outcome measures (PROM) in the immediate postoperative period to detect the perioperative symptom burden and patients' needs which may precede occult and severe complications. The aim of the study was to create a conceptual framework for the development of a PROM to measure perioperative symptom burden in abdominal cancer patients.

METHODS

This mixed method study was performed between March 2021, and July 2021 as part of a multiphase approach to develop a new PROM. A systematic review of the literature was performed health domains were identified. The relevance of the health domains was assessed in a two-round Delphi study with clinical experts. Qualitative interviews were performed in patients who underwent abdominal surgery for cancer.

RESULTS

The systematic literature review yielded 12 different PROM with 168 items and 55 health domains. The most common health domains involved the "digestive system" and "pain". In total, 30 patients (median age 66 years, 20 men [60%]) were included for qualitative patient interviews. Of 16 health domains identified by the Delphi study, a total 15 health domains were confirmed during patients' interviews. The final conceptual framework included 20 health domains.

CONCLUSION

This study provides the essential groundwork to develop and validate a new PROM for the immediate postoperative period of patients undergoing abdominal surgery for cancer.

Relationship between physical activity and bone mineral density loss after gastrectomy in gastric cancer patients

PURPOSE

The prevention of osteoporosis is a particularly relevant issue for gastric cancer survivors. We investigated the relationship between postoperative physical activity and the change of bone mineral density (BMD) in patients with gastric cancer.

METHODS

Patients who underwent radical gastrectomy for gastric cancer were enrolled in this single-center prospective cohort study. Physical activity was evaluated using the International Physical Activity Questionnaire Short Form at postoperative month (POM) 6 and patients were classified into high, middle, and low physical activity groups accordingly. The primary outcome was the change in BMD from baseline at POM 12, which was expressed as a percentage of the young adult mean (YAM). The YAM of the lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry.

RESULTS

One hundred ten patients were enrolled in this study. The physical activity level at POM 6 was classified as high (n = 50; 45%), middle (n = 25; 23%), and low (n = 35; 32%). The mean decrease of YAM% was 5.1% in the lumbar spine and 4.2% in the femoral neck at POM 12. A multivariable-adjusted logistic regression model revealed that low physical activity at POM 6 was a significant risk factor for BMD loss at POM 12 (odds ratio, 3.76; 95% confidence interval, 1.48-9.55; p = 0.005).

CONCLUSION

Low physical activity after gastrectomy is an independent risk factor for decreased BMD at POM 12. The introduction of exercise may prevent osteoporosis after the surgical treatment of gastric cancer.

AGREEMENT BETWEEN UDD APPTM & PROVIDER EVALUATION OF ESOPHAGECTOMY SYMPTOMS IN A MOBILE APP TOOL

BACKGROUND

The objective of this study was to assess the criterion validity of score thresholds for Upper Digestive Disease (UDD) App^TM.

METHODS

From 12/15/2017-12/15/2020, patients presenting after esophagectomy were offered the UDD App^TM concurrent with a provider visit. This tool consists of 67 questions including five novel domains. Score thresholds were used to classify patient as good, moderate, or poor based on domain scores. Providers were given performance descriptions for each domain and asked to classify patients based on their clinical evaluation. The weighted kappa statistic was used to determine the magnitude of agreement between classifications based on the patients' UDD App^TM scores and providers' clinical evaluation.

RESULTS

Fifty-nine patients in the study (76% male), median age 63 [IQR 57, 72] reported outcomes utilizing the UDD app. Providers reviewed between 1-10 patients at a median time of 296.5 days [IQR 50, 975] post-esophagectomy. The magnitude of agreement between patients and providers was moderate for dysphagia (κ= 0.52, p<0.001) and reflux (κ= 0.42, p<0.001). Dumping-related hypoglycemia (κ= 0.03, p=0.148), gastrointestinal complaints (κ= 0.02, p=0.256) and pain (κ= 0.05, p<0.184), showed minimal agreement, with providers underestimating the symptoms and problems reported by patients in these domains.

CONCLUSIONS

Although there was agreement between UDD App^TM assessment and provider evaluation of dysphagia and reflux following esophagectomy, there was discordance of scoring for dumping-related symptoms and pain. Future research is needed to determine whether thresholds for pain and dumping domains need to be revised and/or whether additional provider education on performance descriptions is needed.

Effect of an Early Oral Food Intake Strategy on the Quality of Life of Postoperative Patients With Esophageal Cancer

Objective

To explore the early oral food intake on the quality of life of postoperative patients with esophageal cancer.

Methods

A total of 100 patients with esophageal cancer were randomized into an observation group and a control group, with 50 patients in each group. The patients in the control group were routinely indwelt with a gastric tube and fasted for seven days. If no abnormality was found in examinations, the patients were instructed to attempt drinking water and gradually try eating liquid, semi-liquid, and common foods. The patients in the observation group were subjected to the early oral food intake strategy. The recovery and gastrointestinal symptoms of the patients were evaluated using the six-minute walk test and gastrointestinal symptom rating scale (GSRS) at discharge. The quality of life of patients was evaluated using the QLQ-C30 scale and QLQ-OES18 scale during the return visit to the hospital one month after discharge.

Results

The GSRS score of the observation group was markedly lower than that of the control group. The six-minute walk distance in the observation group was significantly higher than that in the control group; the difference was statistically significant (P < 0.01). In comparing the QLQ-C30 scores of the two groups, the scores in physical function, emotional function, and general health condition in the observation group were higher than those in the control group. In comparing the QLQ-OES18 scores of the two groups, the scores in dysphagia, eating, reflux, pain domains, and choking symptoms in the observation group were lower than those in the control group; the differences were statistically significant (P < 0.01), and there were no statistically significant differences in other symptoms and related functions between the two groups (P > 0.05).

Conclusion

The early oral food intake strategy can reduce gastrointestinal symptoms, promote recovery of postoperative patients with esophageal cancer, and improve quality of life.

Exploratory study of clinical effectiveness and safety of TJ-116 bukuryoingohangekobokuto for anxiety and postoperative water brash in esophageal cancer patients (TJ116E)

BACKGROUND

Patients with esophageal cancer suffer from anxiety in the perioperative period surrounding esophagectomy; this may increase the risk of postoperative complications. In particular, postoperative aspiration pneumonia carries a high risk of hospital mortality. Bukuryoingohangekobokuto (BRIHK) is a traditional Japanese medicine formula used to treat anxiety, the feeling of a foreign body in the esophagus, and water brash. We hypothesize that BRIHK might be effective for both anxiety and water brash in perioperative patients with esophageal cancer. The aim of this study is to evaluate the efficacy and safety of BRIHK compared to a placebo for anxiety and water brash in perioperative esophageal cancer patients.

METHOD/DESIGN

This will be a single-center, single blind, placebo-controlled randomized clinical trial. Twenty-four patients with esophageal cancer undergoing radical resection surgery will be registered to participate, then randomly and blindly assigned to the BRIHK treatment group or control group. Patients will be administered BRIHK or the placebo from 2 weeks before to 6 weeks after surgery. Primary outcome measures will be anxiety and depression (assessed using the Hospital Anxiety and Depression Scale), and water brash (assessed using the 10-item Eating Assessment Tool, Esophagus and Stomach Surgery Symptom Scale, and videofluoroscopy swallowing measurement). Incidences of aspiration pneumonia will be noted and abdominal gas volume, inflammatory markers, and nutrition status will be evaluated.

DISCUSSION

This investigative study will provide clinical evidence of BRIHK administration for anxiety and water brash, which might improve mental distress and reduce postoperative mortality.

TRIAL REGISTRATION

The protocol and progress are registered on the Japan Registry of Clinical Trials (jRCT s021190001) and University Hospital Medical Information Network (UMIN000031330). The protocol was approved by the Japanese Ministry of Health, Labour and Welfare certified clinical research review board, Tohoku University (CRB2180001).

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.

Preliminary Normative Standards of the Mayo Clinic Esophagectomy CONDUIT Tool

Objective

To collect patient-reported outcomes after esophagectomy to establish a set of preliminary normative standards to aid in symptom-score interpretation.

Patients and Methods

Patients undergoing esophagectomy often have little understanding about postoperative symptom management. The Mayo Clinic esophageal CONDUIT tool is a validated questionnaire comprising 5 multi-item symptom-assessment domains and 2 health-assessment domains. A prospective nonrandomized cohort study was conducted on adult patients who have had esophagectomies using the CONDUIT tool from August 17, 2015, to July 30, 2018 (NCT02530983). The Statistical Analysis System v9.4 (SAS Institute Inc., Cary, NC) was used to calculate and analyze the scores.

Results

Over the study period, 569 patients were assessed for eligibility, and 241 patients consented and were offered the tool. Of these, 188 patients (median age: 65 years; range: 24 to 87 years; 80% male patients) had calculable scores. Of the 188 patients, 50 (26.6%) patients were identified as potential beneficiaries for educational intervention to improve symptoms (received moderate scores for a domain), and 131 (69.7%) patients were identified as needing further testing or provider intervention (received poor scores for a domain) based on the tool.

Conclusion

The CONDUIT tool scores, when compared with standardized scales with established preliminary normative scores, could be used to identify and triage patients who need targeted education, further testing, or provider interventions. These score ranges will serve as the first set of normative standards to aid in the interpretation of conduit performance among providers and patients.

Patient-reported outcome domains for the esophageal CONDUIT report card: a prospective trial to establish domains

Background

Health-related quality of life (QoL) deteriorates immediately after esophagectomy. Patients may benefit from periodic assessments to detect increased morbidity on the basis of subjective self-reports. Using input from patients and health care providers, we developed a brief prototype for the esophageal conduit questionnaire (Mayo Clinic Esophageal Conduit Outcomes Noting Dysphagia/Dumping, and Unknown outcomes with Intermittent symptoms over Time after esophageal reconstruction [CONDUIT] Report Card) and previously used it in comparative research. The present study aimed to expand its content and establish health-related QoL and symptom domains of a patient-reported postesophagectomy conduit evaluation tool.

Methods

We expanded tool content by selecting items measuring patient-reported symptoms from existing questionnaires or written de novo. A multidisciplinary group of clinician content-matter experts approved the draft tool, together with a designated patient advocate. The expanded tool was administered to patients postesophagectomy from March 1 to November 30, 2016. We established domains of conduit performance for score reporting through data analysis with exploratory factor analyses. We assessed psychometric properties such as dimensionality, internal consistency, and inter-item correlations in each domain and compared content coverage with other existing measures intended for this patient population. For data that were missing less than 50% of patient responses, the missing values were imputed.

Results

Five multi-item domains were established from data of 76 patients surveyed after esophagectomy; single items were used to assess stricture and conduit emptying. For every multi-item domain, dominance of 1 factor was present. Internal consistency reliability estimates for the domains were 0.87, 0.78, 0.75, 0.80, and 0.83 and average inter-item correlations were 0.40, 0.50, 0.40, 0.33, and 0.73 for dysphagia, reflux, dumping-gastrointestinal symptoms, dumping-hypoglycemia, and pain, respectively. Some items observed to have lower inter-item correlation were reworded or flagged for removal at future validation. For reflux and dumping-related hypoglycemia, additional items were written after these analyses.

Conclusions

The CONDUIT Report Card is a novel questionnaire for assessing QoL and symptoms of patients after esophageal reconstruction. It covers major symptoms of these patients and has good content validity and psychometric properties. The tool can be used to help direct patient care, guide intervention, and compare efficacy of different treatment options.

Trial registration

ClinicalTrials.gov identifier No. 02530983 on 8/18/2015.

Nutrient intake and contribution of home enteral nutrition to meeting nutritional requirements after oesophagectomy and total gastrectomy

BACKGROUND/OBJECTIVES

This study evaluated nutrition after oesophago-gastric resection and the influence of home jejunostomy feeding in the six months after surgery.

SUBJECTS/METHODS

Data on nutritional intake and physiologic measures were collected as part of a randomised trial with measurements taken before and up to six months after surgery.

RESULTS

A total of 41 participants (32 oesophagectomy, 9 total gastrectomy) received home jejunostomy feeding (n=18) or usual care without feeding (n=23). At hospital discharge, oral intakes were adequate for energy and protein in 9% and 6%, respectively. By three and six months, these values had increased to 61% and 55%, 94% and 77% respectively. Six participants (26%) who received usual care required rescue feeding. Six weeks after hospital discharge, energy intakes were met in those who received jejunal feeding because of the contribution of enteral nutrition. Jejunal feeding did not affect oral intake, being similar in both groups (fed: 77% estimated need, usual care: 79%). At three months, inadequate micronutrient intakes were seen in over one third. Compared to baseline values, six weeks after surgery, weight loss exceeding 5% was seen in 5/18 (28%) who received feeding, 14/17 (82%) who received usual care and 5/6 (83%) of those who required rescue feeding, P=0.002. Weight loss averaged 4.1% (fed), 10.4% (usual care) and 9.2% (rescue fed), P=0.004. These trends persisted out to six months.

CONCLUSIONS

Supplementary jejunostomy feeding made an important contribution to meeting nutrition after oesophago-gastric resection. Importantly, oral nutritional intake was not compromised dispelling the assertion that jejunal feeding deincentivises patients from eating.

Effects of barbed suture during robot-assisted radical prostatectomy on postoperative tissue damage and longitudinal changes in lower urinary tract outcome

OBJECTIVE

To compare the postoperative tissue damage and longitudinal changes in functional and patient-reported outcomes after vesicourethral anastomosis with barbed suture and nonbarbed suture in robot-assisted laparoscopic radical prostatectomy (RARP).

MATERIALS AND METHODS

This was a prospective cohort study involving 88 consecutive patients who underwent RARP. These patients were categorized into the barbed suture group (n = 50) and the nonbarbed suture group (n = 38). Urethral and periurethral damages determined by magnetic resonance imaging at nine months after RARP were compared using generalized linear models. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, uroflowmetry, and the 1-h pad test were measured at baseline and at 1, 3, 6, 9, and 12 months after RARP. The findings were analyzed using mixed-effects models. Confounding was adjusted for using propensity score covariate adjustment.

RESULTS

The likelihood of having Grade 2/3 urethral and periurethral damages was greater in the barbed suture group than in the nonbarbed suture group (adjusted risk ratios: 2.98 and 3.85, respectively). IPSS, QOL index, and urinary leakage transiently increased at one month after RARP in both groups. QOL index was higher in the barbed suture group than in the nonbarbed suture group at 1, 9, and 12 months (P = 0.023, P = 0.025, and P = 0.011, respectively). The barbed suture group had significantly more cases of urinary incontinence than the nonbarbed suture group at 3 months (P = 0.041). Other outcomes were comparable between the two groups at all time points.

CONCLUSIONS

This cohort study showed that, after RARP, barbed sutures during VUA induced more severe tissue damage as determined by MRI and greater transient aggravation of QOL and continence function than nonbarbed sutures. The present findings suggest that using nonbarbed sutures during VUA may facilitate earlier acquisition of urinary QOL and urinary continence.

The influence of symptoms on quality of life among patients who have undergone oesophageal cancer surgery

PURPOSE

After oesophagectomy, anatomical changes and loss of function induce various symptoms that may affect quality of life (QoL) in oesophageal cancer patients. The purpose of this study was to identify the factors influencing QoL in Korean patients who have undergone oesophageal cancer surgery.

METHOD

This was a cross-sectional study of a convenience sample consisting of 120 surgery patients with oesophageal cancer. We used the EORTC QLQ-C30 and EORTC QLQ-OES18 to measure participants' oesophageal cancer-related symptoms and QoL. Multiple regression analyses were applied to analyse to the relationship between cancer-related symptoms and QoL.

RESULTS

The average score of oesophageal cancer-related symptoms was 19.28 points, and the most common symptom was reflux. The mean score for global health status/QoL was 60.55. There were significant differences in the functional and symptom subscales according to financial burden, operation type (procedure), and treatment period. Dysphagia most affected global health status/QoL, and eating problems most affected the functional and symptom subscales.

CONCLUSION

Dysphagia and eating problems were confirmed to be the most common symptoms affecting the QoL of patients who had undergone oesophageal cancer surgery. These results can be used to aid in the development of strategies to better manage symptoms in these patients.

Unplanned admission after gastrectomy as a consequence of fast-track surgery: a comparative risk analysis

BACKGROUND

The objectives of this study were to evaluate the incidence of and the risk factors for readmission after gastrectomy. Our hypothesis was that early discharge may be related to an increase in the incidence of readmission.

METHODS

This was a retrospective, single-center, observational study of 1442 patients who underwent gastrectomy for stage I gastric cancer. The main outcome was the incidence of early readmission after gastrectomy, which was defined as an admission within 6 months after the first discharge day. A stepwise logistic regression analysis was conducted to identify the risk factors for readmission after gastrectomy.

RESULTS

The surgical procedures performed were total gastrectomy in 217 patients (15.0 %), distal gastrectomy in 845 patients (58.6 %), pylorus-preserving gastrectomy in 342 patients (23.7 %), and proximal gastrectomy in 37 patients (2.6 %). The median hospital stay was 11 days, and there were 63 readmissions for a total of 56 patients (3.8 %). The main reasons for readmission were poor food intake in 14 patients (22.2 %), anastomotic stricture in nine patients (14.3 %), small bowel obstruction in eight patients (12.7 %), and an abdominal distension in seven patients (11.1 %). Endoscopic balloon dilation was performed for the nine patients with anastomotic stricture, drainage was needed for the four patients with an intra-abdominal abscess, and laparotomy was performed for one patient with adhesion-associated bowel obstruction. The long hospitalization during the primary admission and patients who underwent total gastrectomy were risk factors for readmission.

CONCLUSIONS

Patients with a long hospital stay after gastrectomy are at an increased risk of early readmission, which was likely related to the incidence of severe sequelae specific to gastrectomy.

A systematic review of the nutritional consequences of esophagectomy

BACKGROUND & AIMS

As improved outcomes after esophagectomy have been observed over the last two decades, the focus on care has shifted to survivorship and quality of life. The aim of this review was to determine changes in nutrition after esophagectomy and to assess the evidence for extended nutrition support.

METHODS

A search strategy was developed to identify primary research reporting change in nutritional status a minimum of one month after esophagectomy.

RESULTS

Changes in nutritional parameters reported by 18 studies indicated a weight loss of 5-12% at six months postoperatively. More than half of patients lost >10% of body weight at 12 months. One study reported a persistent weight loss of 14% from baseline three years after surgery. Three studies reporting on longer term follow up noted that 27%-95% of patients failed to regain their baseline weight. Changes in dietary intake (three studies) indicated inadequate energy and protein intake up to three years after surgery. Global quality of life scores reported in one study correlated with better weight preservation. There were a high frequency of gastrointestinal symptoms reported in six studies, most notably in the first year after surgery, but persisting up to 19 years. Extended enteral nutrition on a selective basis has been reported in several studies.

CONCLUSIONS

Nutritional status is compromised in the months/years following oesophagectomy and may never return to baseline levels. The causes/consequences of weight loss/impaired nutritional intake require further investigation. The role of extended nutritional support in this population remains unclear.

Development and Validation of a Disease-Specific Instrument to Measure Diet-Targeted Quality of Life for Postoperative Patients with Esophagogastric Cancer

BACKGROUND

Patients who have undergone esophagectomy or gastrectomy have certain dietary limitations because of changes to the alimentary tract. This study attempted to develop a psychometric scale, named "Esophago-Gastric surgery and Quality of Dietary life (EGQ-D)," for assessment of impact of upper gastrointestinal surgery on diet-targeted quality of life.

METHODS

Using qualitative methods, the study team interviewed both patients and surgeons involved in esophagogastric cancer surgery, and we prepared an item pool and a draft scale. To evaluate the scale's psychometric reliability and validity, a survey involving a large number of patients was conducted. Items for the final scale were selected by factor analysis and item response theory. Cronbach's alpha was used for assessment of reliability, and correlations with the short form (SF)-12, esophagus and stomach surgery symptom scale (ES(4)), and nutritional indicators were analyzed to assess the criterion-related validity.

RESULTS

Through multifaceted discussion and the pilot study, a draft questionnaire comprising 14 items was prepared, and a total of 316 patients were enrolled. On the basis of factor analysis and item response theory, six items were excluded, and the remaining eight items demonstrated strong unidimensionality for the final scale. Cronbach's alpha was 0.895. There were significant associations with all the subscale scores for SF-12, ES(4), and nutritional indicators.

CONCLUSIONS

The EGQ-D scale has good contents and psychometric validity and can be used to evaluate disease-specific instrument to measure diet-targeted quality of life for postoperative patients with esophagogastric cancer.