Improved long-term quality of life in patients with laparoscopy-assisted distal gastrectomy with jejunal pouch interposition for early gastric cancer

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis

Purpose

This study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer.

Materials and Methods

Patients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status.

Results

The length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P<0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P<0.05); the levels decreased more in the nTG group than in the TG group (P<0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P<0.05); however, there was no difference between the groups. Serum vitamin B₁₂, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups.

Conclusions

A small remnant stomach after nTG conferred no significant nutritional benefits over TG.

Predictive factors for body weight loss and its impact on quality of life following gastrectomy

AIM

To determine the predictive factors and impact of body weight loss on postgastrectomy quality of life (QOL).

METHODS

We applied the newly developed integrated questionnaire postgastrectomy syndrome assessment scale-45, which consists of 45 items including those from the Short Form-8 and Gastrointestinal Symptom Rating Scale instruments, in addition to 22 newly selected items. Between July 2009 and December 2010, completed questionnaires were received from 2520 patients with curative resection at 1 year or more after having undergone one of six types of gastrectomy for Stage I gastric cancer at one of 52 participating institutions. Of those, we analyzed 1777 eligible questionnaires from patients who underwent total gastrectomy with Roux-en-Y procedure (TGRY) or distal gastrectomy with Billroth-I (DGBI) or Roux-en-Y (DGRY) procedures.

RESULTS

A total of 393, 475 and 909 patients underwent TGRY, DGRY, and DGBI, respectively. The mean age of patients was 62.1 ± 9.2 years. The mean time interval between surgery and retrieval of the questionnaires was 37.0 ± 26.8 mo. On multiple regression analysis, higher preoperative body mass index, total gastrectomy, and female sex, in that order, were independent predictors of greater body weight loss after gastrectomy. There was a significant difference in the degree of weight loss (P < 0.001) among groups stratified according to preoperative body mass index (< 18.5, 18.5-25 and > 25 kg/m2). Multiple linear regression analysis identified lower postoperative body mass index, rather than greater body weight loss postoperatively, as a certain factor for worse QOL (P < 0.0001) after gastrectomy, but the influence of both such factors on QOL was relatively small (R2, 0.028-0.080).

CONCLUSION

While it is certainly important to maintain adequate body weight after gastrectomy, the impact of body weight loss on QOL is unexpectedly small.

CT gastrography for volumetric measurement of remnant stomach after distal gastrectomy: a feasibility study

PURPOSE

To evaluate the feasibility of post-operative CT gastrography for volumetry of the remnant stomach in gastric cancer patients treated with distal gastrectomy.

METHODS

CT gastrography was performed with oral administration of effervescent granules in 35 gastric cancer patients who underwent distal gastrectomy. Two readers independently rated the degree of gastric distension on a four-point scale, one (near-total collapse) to four (well distended) and measured the volume of remnant stomach using either 3D or 2D volumetry. The inter-volumetry agreements between the 2D and 3D methods and the interobserver agreements between readers 1 and 2 were assessed by intraclass correlation coefficients (ICCs) and Bland-Altman plots.

RESULTS

The mean score of gastric distension was 3.4 ± 0.6 points and 3.4 ± 0.7 points from readers 1 and 2, respectively. We regarded CT images scored with 3-4 points as a technical success for reliable CT volumetry, which achieved a rate of 91.4% (32/35). For the inter-volumetry agreements between 3D and 2D volumetry, the ICCs were 0.9778 and 0.9814 from readers 1 and 2, respectively. The interobserver agreement between readers 1 and 2 was also excellent, with ICCs of 0.9961 and 0.9876 for 2D and 3D volumetry, respectively. On Bland-Altman plots, the means of differences between any pairs of volumetry measurements ranged from -31.1 to 3.2 cm(3), which may be an acceptable range of measurement variability.

CONCLUSIONS

Post-operative CT gastrography is feasible in patients treated with distal gastrectomy. Both 2D and 3D volumetry methods are comparable in measuring the remnant stomach volume.

Reconstruction with Jejunal Pouch after Gastrectomy for Gastric Cancer

The construction of a gastric substitute pouch after gastrectomy for gastric cancer has been proposed to help ameliorate postprandial symptoms and nutritional performance. Adequate reconstruction after gastrectomy is an important issue, because postoperative patient quality of life (QOL) primarily depends on the reconstruction method. To this end, jejunal pouch (JP) reconstructions were developed to improve the patient's eating capacity and QOL by creating large reservoirs with improved reflux barriers to prevent esophagitis and residual gastritis. It is important that such reconstructions also preserve blood and extrinsic neural integrity for maintaining pouch function, because JP motility is associated directly with QOL. Some problems remain to be resolved with the JP reconstructions method including gastrointestinal motility, which plays a major role in food transfer, digestion, and absorption of nutrients. Further studies including basic research and larger prospective randomized control trials are also needed to obtain definitive results. With persistent innovations in surgical techniques, JP after gastrectomy could become a safe and preferable reconstructive modality to improve patient QOL after gastrectomy.

Long-term comparison of boomerang-shaped jejunal interposition and Billroth-I reconstruction after distal gastrectomy

BACKGROUND

Billroth-I (BI) is a simple, physiological method of reconstruction following distal gastrectomy. In actuality, postoperative QOL is by no means favorable due to the high incidence of post-gastrectomy syndrome. The aim of this study is to assess the safety and efficacy of boomerang-shaped jejunal interposition (BJI) after distal gastrectomy.

METHODS

Sixty-six patients with early gastric cancer underwent the BI procedure (n = 33) or BJI (n = 33) after distal gastrectomy, following which they were compared for 5 years. Tumor characteristics, operative details, postoperative complications and complaints, number of meals, and body weight were analyzed. Patients were followed up by endoscopy every 12 months.

RESULTS

There were no significant differences in the incidence of postoperative complications. The incidence of heartburn (30 vs. 0 %, P = 0.0009) and oral bitterness (33 vs. 6 %, P = 0.0112) were significantly lower in the BJI cases. Endoscopic findings revealed significantly lower incidences of reflux esophagitis (24 vs. 0 %, P = 0.0051) and remnant gastritis (70 vs. 3 %, P < 0.0001) in the BJI group. The incidence of food stasis was low in both groups (12 vs. 15 %). In the BJI group, 30 patients (90 %) were eating 3 meals/day within 12 months, whereas in the BI group, 16 patients (48 %) were still eating 5 meals/day at 12 months or later.

CONCLUSIONS

BJI is as safe as BI, but is better in terms of improvement in bile reflux and food intake without stasis. This procedure, therefore, appears to be a useful method for reconstruction after distal gastrectomy.

Clinical effects of preoperative selective arterial chemotherapy in patients with advanced gastric cancer

AIM: To assess the clinical effects of preoperative selective arterial chemotherapy in patients with locally advanced gastric cancer.

METHODS: Twenty-five patients with advanced gastric cancer treated by preoperative arterial chemotherapy and radical surgery at our hospital from March 2009 to March 2013, and 25 patients with advanced gastric cancer undergoing conventional surgery during the same time period were included in the study. Clinical effects were compared between the two groups.

RESULTS: No patient experienced severe postoperative reaction. The tumor invasion scope in the surgical margin was significantly smaller in the study group. The study group had significantly better survival than the control group, and all 25 patients underwent radical surgery, with a 3-year postoperative survival rate of 84.0%.

CONCLUSION: Preoperative selective arterial chemotherapy can significantly improve the survival of patients with advanced gastric cancer.

History of minimally invasive surgery for gastric cancer in Korea

Laparoscopic gastrectomy was begun in 1995 in Korea. But, there was 4 years gap to reactivate in 1999. High incidence of gastric cancer and increasing proportion of early cancer through national screening program along with huge effort and enthusiasm of laparoscopic gastric surgeon, and active academic exchange with Japanese doctors contributed development of laparoscopic gastrectomy in Korea. Study group activity of Korean Laparoscopic Gastrointestinal Surgery Study (KLASS) group and Collaborative Action for Gastric Cancer (COACT) group were paramount to evoke large scale multicenter clinical study and various well performed clinical studies. This review encompasses mainly international publications about this area so far in Korea.

The quality of life trajectory of resected gastric cancer

BACKGROUND

Few studies describe quality of life (QoL) outcomes following gastrectomy for gastric cancer using a validated instrument. The gastric cancer module for the Functional Assessment of Cancer Therapy system of QoL measurement tools (FACT-Ga) was utilized to determine the changes in QoL following gastrectomy, and during the disease course.

METHODS

In 43 patients undergoing gastrectomy for gastric cancer, outcome such as complications, recurrence, and survival were annotated. Karnofsky performance status (KPS) and QoL were determined preoperatively and at each follow-up visit.

RESULTS

Nineteen (44%) patients and 24 (56%) patients underwent partial gastrectomy (PG) and total gastrectomy (TG), respectively. Complications occurred in 30%, and one mortality (2.3%) occurred. Median survival was 23 months. KPS, FACT-G, and FACT-Ga scores all decreased after surgery, and normalized by 6 months. There was no significant difference in QoL in patients who had a PG or TG, although the type of gastrectomy did affect KPS. QoL dropped on average 4.4 ± 3.6 months prior to death.

CONCLUSIONS

Surgery adversely affects QoL for up to 6 months. Thereafter, QoL mirrors changes in disease status. More studies are required to document the QoL cost-benefit ratio in gastric cancer, which often is accompanied by short survival benefits.

Gastric malignancy: surgical management

PURPOSE OF REVIEW

To highlight the recent changes and development in the surgical management of gastric adenocarcinoma. There is significant development in the field. However, issues like extent of resection, lymphadenectomy, and minimal access approach are still to be refined for clinical and oncological effectiveness and safety.

RECENT FINDINGS

The outcomes of surgical treatment of gastric adenocarcinoma are improving due to several factors, including specialist unit settings, refinement of the surgical techniques, improved adequacy of lymphadenectomy and some other minor factors such as multidisciplinary team approach and the use of perioperative chemotherapy or radiotherapy. The most hot issue in the past year's literatures is the use of minimal access surgery for resection and lymphadenectomy. The trend of studies is supporting minimal access approach for limited, subtotal and even total gastrectomy.

SUMMARY

The outcomes of surgical treatment of gastric adenocarcinoma are improving. Minimal access approach to treat gastric adenocarcinoma is evolving and continuing to have a substantial role in current surgical practice. The potential role of minimal access surgery, surgical resectional techniques, extent of lymphadenectomy and setting of specialized units and multidisciplinary team approach have stimulated an active research.