Clinical outcomes and quality of life according to types of reconstruction following laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Laparosc Endosc Percutan Tech. 2015;25:69-73. [PMID: 24743669 DOI: 10.1097/sle.0000000000000021]

Night home enteral nutrition as a novel enforced and physiologically effective nutrition therapy following total gastrectomy for gastric cancer

Enteral nutrition has been reported to be safe and effective in malnourished patients undergoing upper gastrointestinal surgery. In this study, we devised night home enteral nutrition (N-HEN) as a novel nutritional strategy and evaluated the efficacy in gastric cancer patients following total gastrectomy. Between January 2017 and March 2021, 24 patients were prospectively included in the protocol and supported by N-HEN for three postoperative months through a jejunostomy during the night (Elental:1200 kcal/day), and 22 patients without N-HEN were followed as a control group (CG). Body weight loss, nutritional indicators and tolerance to chemotherapy were evaluated. After 3 and 6 months, patients with N-HEN had significantly less body weight loss than CG (3 months P < 0.0001: N-HEN 4.0% vs. CG 15.2%, 6 months P < 0.0001: N-HEN 7.7% vs. CG 17.7%). Prealbumin was significantly higher in patients with N-HEN than CG after 3 and 6 months (3 months P < 0.0001, 6 months P = 0.0037). Albumin, total protein and hemoglobin, tended to be higher after 3 and 6 months in patients with N-HEN than CG, and total cholesterol after 6 months. Concerning the tolerance to adjuvant chemotherapy in Stage II-III patients, patients with N-HEN significantly had a higher completion rate (P = 0.0420: N-HEN 70% vs. CG 29%) and longer duration (P = 0.0313: N-HEN 458 days vs. CG 261 days) as planned. Continuous monitoring of blood glucose concentration in patients with N-HEN did not show nocturnal hypoglycemia or hyperglycemia. N-HEN could be a novel enforced and physiologically effective nutritional strategy to support potentially malnourished patients following total gastrectomy.

Comparison of the gastric microbiome in Billroth I and Roux-en-Y reconstructions after distal gastrectomy

The changes in gastric microbiota following reconstruction after gastrectomy have not been reported. This study aimed to compare the gastric microbiota following Billroth I and Roux-en-Y reconstructions after distal gastrectomy. We enrolled 71 gastrectomized patients with gastric cancer; 31 and 40 underwent Billroth I and Roux-en-Y reconstructions, respectively. During upper gastrointestinal endoscopy, gastric fluid was collected immediately before and 6 months after distal gastrectomy. Deoxyribonucleic acid isolated from each sample was evaluated using 16S ribosomal ribonucleic acid metagenomic analysis. Analysis revealed that the gastric microbiota’s species richness (expressed as the alpha diversity) was significantly lower after than before distal gastrectomy (operational taxonomic units, p = 0.001; Shannon index, p = 0.03). The interindividual diversity (beta diversity) was significantly different before and after distal gastrectomy (unweighted UniFrac distances, p = 0.04; weighted UniFrac distances, p = 0.001; Bray–Curtis, p = 0.001). Alpha and beta diversity were not significantly different between Billroth I and Roux-en-Y reconstructions (observed operational taxonomic units, p = 0.58; Shannon index, p = 0.95; unweighted UniFrac distances, p = 0.65; weighted UniFrac distances, p = 0.67; Bray–Curtis, p = 0.63). Our study demonstrated significant differences in gastric microbiota diversity, composition, and community before and after distal gastrectomy but no difference between Billroth I and Roux-en-Y reconstruction after distal gastrectomy.

A comparison of quality of life between patients with small and large gastric remnant volumes after gastrectomy for gastric cancer

The impact of gastric remnant volumes (GRVs) after gastrectomy on patients' quality of life (QOL) has not yet been clarified. The aim of the present study was to compare QOL after gastrectomy between small and large gastric remnant volume patients.We prospectively collected clinical data from 78 consecutive patients who underwent distal gastrectomy with Billroth II gastrojejunostomy for gastric cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach questionnaire and gastric computed tomography scans were performed. The patients were subdivided into 2 groups by remnant stomach volume (the S group ≤110 mL vs L group >110 mL).The worst scores for most items were observed at postoperative month 1 and usually improved thereafter. There was no difference in the STO22 score except for dysphagia between the S and L groups after gastrectomy (P > .05). The QOL score of dysphagia was different at postoperative 6 months (S vs L, 12.4 vs 22.8, P < .03), but there was no difference at postoperative months 1, 3, 12, 24, or 36 (P > .05).The remnant gastric volume after partial gastrectomy affects neither functional differences nor QOL after 6 months following appropriate radical surgery.

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.

Billroth-I vs Roux-en-Y after distal gastrectomy: A comparison of long-term nutritional status and survival rates from a large-scale multicenter cohort study

BACKGROUND

The optimal standard reconstruction procedure after distal gastrectomy is controversial. No large-scale persuasive clinical studies from long-term perspectives on this topic have yet been conducted.

STUDY DESIGN

This retrospective multicenter study analyzed a database of 2510 consecutive patients with clinical stage I gastric cancer who underwent distal gastrectomy followed by Billroth-I (B-I) or Roux-en-Y (R-Y) anastomosis from 2006 to 2012. After adjusting for 30 potential confounding factors using propensity score matching, we compared the body weight loss and other nutritional status for 5 years as primary outcomes between the two groups. We also investigated surgical outcomes, endoscopic findings, and long-term survival rates as secondary outcomes.

RESULTS

After matching the inclusion criteria, 940 patients (470 in each group) were enrolled. There was no marked difference in the body weight loss and other nutritional indicators. The incidence of grade ≥3 postoperative complications (Clavien-Dindo classification) or the incidence of gallstone formation was not markedly different between the two groups. The postoperative hospital stay after surgery was significantly longer, and the readmission rate was significantly higher in the R-Y group than in the B-I group. An endoscopic examination revealed no trends regarding the incidence and severity of gastritis or residual food in the remnant stomach. The 5-year overall survival rate was 92.6% in the B-I group and 91.8% in the R-Y group, with no significant difference (P = .379, log-rank test).

CONCLUSIONS

Roux-en-Y reconstruction may be nearly equal to Billroth-I with regard to the long-term nutritional perspectives.

Risk Factors for Duodenal Stump Leakage after Laparoscopic Gastrectomy for Gastric Cancer

Purpose

Duodenal stump leakage (DSL) is a potentially fatal complication that can occur after gastrectomy, but its underlying risk factors are unclear. This study aimed to investigate the risk factors and management of DSL after laparoscopic radical gastrectomy for gastric cancer (GC).

Materials and Methods

Relevant data were collected from several prospective databases to retrospectively analyze the data of GC patients who underwent Billroth II (B-II) or Roux-en-Y (R-Y) reconstruction after laparoscopic gastrectomy from 2 institutions (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, and HwaMei Hospital, University of Chinese Academy of Sciences). The DSL risk factors were analyzed using univariate and multivariate analysis regression.

Results

A total of 810 patients were eligible for our analysis (426 with R-Y, 384 with B-II with Braun). Eleven patients had DSL (1.36%). Body mass index (BMI), elevated preoperative C-reactive protein (CRP) level, and unreinforced duodenal stump were the independent risk factors for DSL. DSL was diagnosed in 2–12 days, with a median of 8 days. Seven patients received conservative treatment, 3 patients received puncture treatment, and only 1 patient required reoperation. All patients recovered successfully after treatment.

Conclusions

The risk factors of DSL were BMI ≥24 kg/m², elevated preoperative CRP level, and unreinforced duodenal stump. Nonsurgical treatments for DSL are preferred.

Four reconstruction methods after laparoscopic distal gastrectomy: A systematic review and network meta-analysis

BACKGROUND

There is no consensus regarding which reconstruction methods are superior after laparoscopic distal gastrectomy (LDG). This study compared four reconstruction methods after LDG for gastric cancer.

METHODS

Literature in EMBASE, PubMed, and the Cochrane Library was screened to compare Billroth I (B-I), Billroth II (B-II), Roux-en-Y (RY), and uncut Roux-en-Y (URY) anastomoses after LDG for gastric cancer. A Bayesian network meta-analysis (NMA) was conducted to compare these methods.

RESULTS

Eighteen studies involving 4347 patients were eligible for our NMA. The operative time in RY anastomosis was longer than that in B-I and B-II anastomoses. Blood loss and risk of gastrointestinal motility dysfunction were greater with RY anastomosis than with URY or B-I anastomosis. Furthermore, URY anastomosis was superior to the other 3 reconstruction methods for preventing food residue. For remnant gastritis, RY anastomosis was significantly superior to B-I and B-II anastomoses, whereas URY anastomosis was significantly superior to B-II anastomosis. In addition, RY and URY anastomoses were better than B-I and B-II anastomoses for preventing bile reflux.

CONCLUSIONS

URY anastomosis tended to be a more favorable reconstruction method after LDG due to its operative simplicity and reduced long-term complications.

Comparison of Quality of Life and Nutritional Status of Between Roux-en-Y and Billroth-I Reconstruction After Distal Gastrectomy: A Systematic Review and Meta-Analysis

Background: This paper purports to use a meta-analysis to compare the postoperative quality of life (QoL) and nutritional status of between Roux-en-Y (R-Y) and Billroth-I (B-I) reconstruction after distal gastrectomy.Methods: For this study, the following databases were searched for articles published from inception until December 2018: PubMed, Web of Science, EBSCO, and Cochrane library.Results: A total of 13 eligible studies, covering 3645 patients, were selected for a meta-analysis. The analysis showed that compared with B-I group in term of short-term outcomes, patients undergoing R-Y reconstruction did not only have significantly better physiological function (P = 0.02), but had significantly less pain (P = 0.04). In the long-term outcomes, the dyspnea and constipation in the B-I group were worse than that in the R-Y group (P = 0.004; P = 0.04, respectively). Patients in the B-I group had higher cholesterol than those in the R-Y group at 5 years postoperatively (P = 0.003). There were no significant differences in termof other nutritional indicators including total protein, cholesterol, albumin, hemoglobin and weight in short-term outcomes.Conclusions: The final conclusion was that R-Y may be superior to the B-I reconstruction in some aspects of QoL. Besides, R-Y reconstruction could reduce the patient's cholesterol level for a long time. For the short-term outcomes, there were no significant differences in other common nutritional indicators.

The Development and Future of Digestive Tract Reconstruction after Distal Gastrectomy: A Systemic Review and Meta-Analysis

Background: Billroth I, Billroth II, Roux-en-Y, and Un-cut Roux-en-Y are common reconstruction techniques of distal gastrectomy. Which of these techniques is better has yet to be established. We performed an indirect comparison to evaluate which technique was optimal for preventing reflux symptoms.

Methods: The PubMed, Cochrane Collaboration, Embase, ClinicalTrials.gov and Web of Science databases were searched to identify clinical trials that compared at least two of the reconstruction skills among Billroth I, Billroth II, Roux-en-Y, and Un-cut Roux-en-Y. Data on reflux gastritis, intraoperative blood loss, bile reflux and postoperative hospital stays were extracted from the included clinical trials for meta-analysis using a random-effects model.

Results: Twenty-four articles that included 5419 individuals were assessed as eligible for meta-analysis. The indirect comparison suggested that Roux-en-Y reconstruction significantly reduces reflux gastritis, and it tended to rank first and had the highest probability of preventing bile reflux. No significant differences were found in intraoperative blood loss and postoperative hospital stays.

Conclusion: This indirect comparison suggested some superiority of Roux-en-Y reconstruction after distal gastrectomy. Further perspective clinical trials are required to provide evidence for the optimal reconstruction skill.

Comparison of the Physiological Effect of Billroth-I and Roux-en-Y Reconstruction Following Laparoscopic Distal Gastrectomy

BACKGROUND

Laparoscopic distal gastrectomy (LDG) is a widely used minimally invasive surgery. Following LDG, Billroth-I (B-I) provides physiological reconstruction by preserving the duodenal passage but results in a high incidence of reflux esophagitis that decreases postoperative quality of life. Because of this, Roux-en-Y (R-Y) reconstruction is often considered the first choice after LDG. However, very few studies have investigated differences in physiological function between B-I and R-Y after LDG. We hypothesized that B-I would outperform R-Y in clinical and physiological outcomes, including nutrition parameters.

METHODS

We compared hemoglobin, ferritin, serum iron, Vitamin B12, 25(OH)-Vitamin D (V-D), body weight, and gastric emptying after LDG in patients with either B-I or R-Y reconstruction.

RESULTS

The levels of hemoglobin in the B-I group were significantly higher than that in the R-Y group at all time points later than 6 months postsurgery. The ferritin levels were significantly higher in the B-I group at all time points later than 9 months postsurgery. The concentration of serum V-D in the B-I group was significantly higher than that in the R-Y group at 1 year 6 months, 1 year 9 months, and 2 years after surgery. Gastric emptying in the R-Y group was significantly slower than in the B-I group.

CONCLUSIONS

Our data indicate that B-I leads to less postsurgical iron deficiency anemia and V-D deficiency compared with R-Y reconstruction. Furthermore, gastric emptying was preserved in B-I reconstruction compared with R-Y reconstruction. In conclusion, after LDG, B-I reconstruction seems to cause fewer nutritional complications than R-Y reconstruction.

Reconstruction method as an independent risk factor for postoperative bone mineral density loss in gastric cancer

BACKGROUND AND AIM

No study has compared the incidence of postoperative bone metabolic disorders between Billroth-I (B-I) and Roux-en-Y (R-Y) reconstructions after distal gastrectomy (DG) for gastric cancer (GC). In this study, we wished to examine the impact of reconstruction method on postoperative bone mineral density (BMD) loss.

METHODS

We investigated a total of 148 consecutive patients who underwent DG with B-I or R-Y reconstruction for stage I GC between 2008 and 2012. We retrospectively assessed the BMD data using computed tomography attenuation values of the first lumbar vertebra after surgery.

RESULTS

In multivariate analysis for the whole study series, R-Y reconstruction was identified as an independent risk factor for BMD loss after DG (P < 0.0001; OR = 5.60; 95% CI = 2.38-13.98). Propensity score match analysis was used to overcome bias because of the different covariates for the two groups; even though the 37 patients in the B-I group and the 37 patients in the R-Y group had no significant difference among characteristics, B-I reconstruction was validated to have superiority over R-Y reconstruction for preventing BMD loss in the first 3 years after DG. The cumulative hazard ratio of osteoporosis after gastrectomy was significantly higher in the R-Y group than in the B-I group (P = 0.0427).

CONCLUSIONS

Billroth-I reconstruction might be a preferable method for preventing BMD loss after gastrectomy in GC patients.

A comparative study of delta-shaped and conventional Billroth I anastomosis after laparoscopic distal gastrectomy for gastric cancer

BACKGROUND

Delta-shaped anastomosis (DA) is a newly developed intracorporeal gastroduodenostomy. This meta-analysis is performed to compare the safety, feasibility and clinical outcomes of DA with conventional extracorporeal Billroth I anastomosis (B-I) after laparoscopic distal gastrectomy for gastric cancer.

METHODS

Both randomized controlled trials (RCTs) and nonrandomized cohort studies comparing outcomes of DA and B-I after laparoscopic distal gastrectomy for gastric cancer were searched in electronic database. Surgical outcomes, postoperative recovery, postoperative complications and outcomes were pooled and compared by meta-analysis using RevMan 5.3 software. Weighted mean differences (WMDs), odds ratios and risk differences were calculated with 95% confidence intervals (CIs). P values of <0.05 were considered statistically significant.

RESULTS

Eight nonrandomized cohort studies of 2450 patients were included. Meta-analysis showed significantly less blood loss (WMD -28.72; 95% CI -49.21 to -8.23; P = 0.006), more lymph nodes retrieved (WMD 3.23; 95% CI 0.86-5.61; P = 0.008), shorter time to first soft diet (WMD -0.34; 95% CI -0.47 to -0.21, P < 0.00001), less pain and analgesic use (WMC -0.29; 95% CI -0.56 to -0.02; P = 0.03) in DA than in B-I. Both methods had similar operative time, resection margin, time to first flatus, length of hospital stay and rate of complications. Most of the postoperative symptoms were comparable between groups. The subgroup of obese patient showed more favorable outcomes in DA, and the learning curve of DA is steep.

CONCLUSION

DA is a safe and feasible reconstruction method after laparoscopic distal gastrectomy, with comparable postoperative surgical outcomes, postoperative complications comparing to B-I. DA is less invasive with quicker resume of diet than B-I, especially for the obese patients.

Quality of life: A critical outcome for all surgical treatments of gastric cancer

Surgery represents the main curative therapeutic modality for gastric cancer, and it is occasionally considered for palliation as well as prophylaxis. Most frequently, surgical outcomes are conveyed in terms of oncological outcomes such as recurrence and survival. However, quality of life (QoL) is also important and should be considered when making treatment decisions - including the extent of and approach to surgery. Measurement of QoL usually involves the application of questionnaires. While there are multiple QoL questionnaires validated for use in oncology patients, there are very few that have been validated for use in those with gastric cancer. In this review, we discuss and compare the current status of QoL questionnaires in gastric cancer. More importantly, the impact of surgery for treatment, palliation and prophylaxis of gastric cancer on QoL will be described. These data should inform the surgeon on the optimal approach to treating gastric cancer, taking into account oncological outcomes. Knowledge gaps are also identified, providing a roadmap for future studies.