Longitudinal Analysis of Quality-of-Life Recovery After Gastrectomy for Cancer

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Gastric Cancer Survivorship: Multidisciplinary Management, Best Practices and Opportunities

PURPOSE

Gastric cancer is the 5th most common malignancy worldwide. As early detection increases and treatments for gastric cancer improve, the number of gastric cancer survivors grows.

METHODS

Here, we review the diagnosis and management of gastric cancer and discuss important considerations for gastric cancer survivorship including cancer surveillance, weight loss, malnutrition, fatigue, specific complications related to surgery and radiation, quality of life in gastric cancer survivorship, health behavior, and models of survivorship.

RESULTS

Multimodality therapy with chemotherapy and surgery can result in chronic toxicities in multiple organ systems. This emphasizes the need for a multidisciplinary survivorship care model including cancer surveillance, management of chronic toxicities, and optimization of modifiable risk factors with long-term involvement of appropriate providers.

CONCLUSION

Adequately caring for gastric cancer survivors requires a coordinated, multidisciplinary approach.

Textbook oncological outcomes and prognosis after curative gastrectomy in advanced gastric cancer: A multicenter study

BACKGROUND

The impact of achieving textbook oncological outcome (TOO) as a multimodal therapy quality indicator on the prognosis of advanced gastric cancer (AGC) remains inadequately assessed.

METHODS

Patients with AGC who underwent curative gastrectomy between January 2010 and December 2017 at two East Asian medical centers were included. TOO was defined as achieving the textbook outcome (TO) and receiving neoadjuvant and/or adjuvant chemotherapy (NCT or ACT). Cox and logistic regression models were used to identify prognostic and non-TOO-associated risk factors.

RESULTS

Among 3626 patients, 57.6% achieved TOO (TOO group), exhibiting significantly better 5-year overall survival (OS) and disease-free survival (DFS) than the non-TOO group (both p < 0.05). Multivariate Cox regression identified TOO as an independent prognostic factor for 5-year OS (HR, 0.67; 95% CI, 0.61-0.74; p < 0.001) and DFS (HR, 0.73; 95% CI, 0.66-0.81; p < 0.001). Multivariate logistic regression showed that open gastrectomy, lack of health insurance, age ≥65 years, ASA score ≥ Ⅲ, and tumor size ≥50 mm are independent risk factors for non-achievement of TOO (all p < 0.05). On a sensitivity analysis of TOO's prognostic value using varying definitions of chemotherapy parameters, a stricter definition of chemotherapy resulted in a decrease in the TOO achievement rate from 57.6 to 22.3%. However, the associated reductions in the risk of death and recurrence fluctuated within the ranges of 33-39% and 28-37%, respectively.

CONCLUSIONS

TOO is a reliable and stable metric for favorable prognosis in AGC. Optimizing the surgical approach and improving health insurance status may enhance TOO achievement.

Students and physicians differ in perception of quality of life in patients with tumors of the upper gastrointestinal tract

Health-related quality of life (HRQoL) has recently gained importance as treatment options for tumors of the upper GI tract lead to improved long-term survival. HRQoL is often estimated by physicians even though their reliability and the impact of outside factors such as contact time and level of medical education is unclear. Therefore, in this study we investigated the correlation between physicians', students', and patients' assessment of HRQoL. 54 patients presenting with tumors of the upper GI tract were included and asked to fill out the standardized HRQoL questionnaires EORTC QLQ-C30 and QLQ-OG25. Attending physicians and medical students filled out the same questionnaires through estimation of patients' HRQoL. Correlation was assessed through Pearson's and Kendall's τb coefficients. Physicians' and patients' assessments correlated for one out of six of the functional and a third of the symptom scores. Students' and patients' assessments correlated for one third of the functional and two thirds of the symptom scores. Students tended to underestimate patients' symptom burden while physicians tended to overestimate it. Physicians failed to correctly assess several pathognomonic symptoms in this study. Students showed higher correlation with patients' symptoms than physicians. Even so, this adds to mounting evidence that shows the benefit of using patient-reported outcomes as a gold standard regarding HRQoL.

Risk Factors, Management, and Outcome of Gastric Venous Congestion After Total Pancreatectomy: An Underestimated Complication Requiring Standardized Identification, Grading, and Management

BACKGROUND

Gastric venous congestion (GVC) after total pancreatectomy (TP) is rarely studied despite its high 5% to 28% incidence and possible association with mortality. This study aimed to provide insight about incidence, risk factors, management, and outcome of GVC after TP.

METHODS

This retrospective observational single-center study included all patients undergoing elective TP from 2008 to 2021. The exclusion criteria ruled out a history of gastric resection, concomitant (sub)total gastrectomy for oncologic indication(s) or celiac axis resection, and postoperative (sub)total gastrectomy for indication(s) other than GVC.

RESULTS

The study enrolled 268 patients. The in-hospital major morbidity (Clavien-Dindo grade ≥IIIa) rate was 28%, and the 90-day mortality rate was 3%. GVC was identified in 21% of patients, particularly occurring during index surgery (93%). Intraoperative GVC was managed with (sub)total gastrectomy for 55% of the patients. The major morbidity rate was higher for the patients with GVC (44% vs 24%; p = 0.003), whereas the 90-day mortality did not differ significantly (5% vs 3%; p = 0.406). The predictors for major morbidity were intraoperative GVC (odds ratio [OR], 2.207; 95% confidence interval [CI], 1.142-4.268) and high TP volume (> 20 TPs/year: OR, 0.360; 95% CI, 0.175-0.738). The predictors for GVC were portomesenteric venous resection (PVR) (OR, 2.103; 95% CI, 1.034-4.278) and left coronary vein ligation (OR, 11.858; 95% CI, 5.772-24.362).

CONCLUSIONS

After TP, GVC is rather common (in 1 of 5 patients). GVC during index surgery is predictive for major morbidity, although not translating into higher mortality. Left coronary vein ligation and PVR are predictive for GVC, requiring vigilance during and after surgery, although gastric resection is not always necessary. More evidence on prevention, identification, classification, and management of GVC is needed.

Efficacy and safety of totally laparoscopic gastrectomy with uncut Roux-en-Y for gastric cancer: a dual-center retrospective study

BACKGROUND

Uncut Roux-en-Y (URY) effectively alleviates the prevalent complexities connected with RY, such as Roux-en-Y stasis syndrome (RSS). Nevertheless, for gastric cancer (GC) patients, it is still controversial whether URY has an impact on long-term prognosis and whether it has fewer afferent loop recanalization. Therefore, compare whether URY and RY have differences in prognosis and long-term complications of GC patients undergoing totally laparoscopic gastrectomy (TLG).

METHODS

We analyzed the data of patients who underwent TLG combined with digestive tract reconstruction from dual-center between 2016 and 2022. Only patients undergoing URY and RY were selected for analysis. Relapse-free survival (RFS) and overall survival (OS) were estimated. Bias between the groups was reduced by propensity score matching (PSM). The Cox proportional hazard regression model was used to further analyze the influence of URY on prognosis.

RESULTS

Two hundred forty two GC patients were enrolled. The URY had significantly shorter operation time, liquid food intake time, and in-hospital stays than the RY (P < 0.001). The URY had fewer long-term and short-term postoperative complications than the RY, especially with regard to RSS, reflux esophagitis, and reflux gastritis. The 3-year and 5-year OS of the URY group and the RY group before PSM: 87.5% vs. 65.6% (P < 0.001) and 81.4% vs. 61.7% (P = 0.001). PSM and Cox multivariate analysis confirmed that compared to RY, URY can improve the short-term and long-term prognosis of GC patients.

CONCLUSION

TLG combined with URY for GC, especially for advanced, older, and poorly differentiated patients, may promote postoperative recovery and improve long-term prognosis.

Electro-acupuncture for health-related quality of life and symptoms in patients with gastric cancer undergoing adjuvant chemotherapy (EAGER): a protocol for a multicenter randomized controlled trial

BACKGROUND

Patients with local gastric cancer experience a decline of Health-related quality of life (HRQOL) during adjuvant chemotherapy following gastrectomy. Our previous pilot study has indicated the potential of acupuncture to improve HRQOL and control cancer-related symptoms burden. This full-scale trial will focus on confirming the effect of acupuncture for patients with gastric cancer.

METHODS

A multicenter, open-label, three-arm randomized controlled trial with 249 patients will be conducted in China. Patients will be randomly assigned, in a ratio of 1:1:1, to receive high-dose acupuncture (HA, 7 times each chemo-cycle for 3 cycles), low-dose acupuncture (LA, 3 times each chemo-cycle for 3 cycles), or no acupuncture. The acupoints prescription consisted of bilateral ST36, PC6, SP4, DU20, EX-HN3, and selected Back-shu points. Patients-reported Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) and modified Edmonton Symptom Assessment Scale (mESAS) during the therapy will be recorded. Area under curve (AUC, 21 days/cycle × 3 cycles) and average trajectory of FACT-Ga and mESAS will be calculated. The primary outcome will be the differences in AUC of the FACT-Ga Trial Outcome Index (TOI) between HA and LA versus control groups. Secondary outcomes include AUCs and average trajectory of other FACT-Ga subscales and mESAS scores.

DISCUSSION

This study aims to assess the effect of acupuncture and to compare the difference between LA and HA groups on HRQOL and symptom burden controlling in gastric cancer patients by an adequately powered trial.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of the Guangdong Provincial Hospital of Traditional Chinese Medicine (approval number: BF2018-118) with registration at ClinicalTrials.gov (identifier: NCT04360577).

The Predictive Value of a New Inflammatory-Nutritional Score for Quality of Life after Laparoscopic Distal Gastrectomy for Gastric Cancer

We explored the predictive value of various inflammatory-nutritional indicators for postoperative quality of life (QoL) in gastric cancer (GC) patients undergoing laparoscopic distal gastrectomy (LDG) and developed a novel inflammatory-nutritional score (INS). In this study, 156 GC patients who underwent LDG were included. We used multiple linear regression to analyze the correlation between postoperative QoL and inflammatory-nutritional indicators. Least absolute shrinkage and selection operator (LASSO) regression analysis was performed to construct INS. Hemoglobin was positively correlated with physical functioning (β =8.5; p = 0.003) and cognitive functioning (β = 3.5; p = 0.038) 3 mo, after surgery. Prognostic nutritional index (PNI) was positively associated with global health status (β =5.8; p = 0.043). Albumin-alkaline phosphatase ratio (AAPR) was negatively correlated with emotional functioning 12 mo, after surgery (β = -5.7; p = 0.024). Neutrophil-lymphocyte ratio (NLR), Lymphocyte- monocyte ratio (LMR), AAPR, hemoglobin and PNI were selected using LASSO regression analysis to construct INS. The C-index values of the model in the training group and the validation group were 0.806 (95% CI, 0.719-0.893) and 0.758 (95% CI: 0.591-0.925), respectively. INS had particular predictive value for postoperative QoL in patients undergoing LDG and provided a reference for risk stratification and clinical practice.

A web-based calculator combining Geriatric Nutritional Risk Index (GNRI) and Tilburg Frailty Indicator (TFI) predicts postoperative complications among young elderly patients with gastric cancer

AIM

Nutritional status and frailty are significant indicators reflecting physiological reserve. We sought to establish and validate a web-based calculator containing the Geriatric Nutritional Risk Index (GNRI) and the Tilburg Frailty Indicator (TFI) together with general clinical information to predict total complications among elderly patients with gastric cancer.

METHODS

This was a prospective cohort study of 582 elderly patients with gastric cancer in a tertiary hospital in China. Nutritional status and frailty were assessed by the GNRI and the TFI, respectively. The nomogram was built and further converted into a web-based calculator. The receiver operating characteristic analysis was performed to evaluate the discrimination of the nomogram. Calibration was assessed using the calibration curve and Hosmer-Lemeshow test via the bootstrap resampling procedure. The decision curve analyses (DCAs) were employed to quantify the net benefits of a certain threshold probability for assessing the clinical values.

RESULTS

The GNRI (odds ratio [OR], 0.921; 95% confidence interval [CI], 0.895-0.949; P < 0.001), the TFI (OR, 1.243; 95% CI, 1.113-1.386; P < 0.001), surgical approach (OR, 1.913; 95% CI, 1.073-3.408; P = 0.028) and comorbidity (OR = 1.599, 95%CI = 1.028-2.486, P = 0.037) were independently associated with total complications. The nomogram demonstrated good discrimination (area under the receiver operating characteristic curve: training cohort, 0.735; validation cohort, 0.777) and calibration (P = 0.135). The DCA curves of the nomogram also showed good positive net benefits.

CONCLUSIONS

The web-based calculator incorporating the GNRI, the TFI, surgical approach, and comorbidity could successfully predict total complications among elderly patients with gastric cancer with good accuracy in a convenient manner. Geriatr Gerontol Int 2023; 23: 205-212.

The impact of the 30-day postoperative complications on the quality of life following gastrectomy for gastric carcinoma: A prospective study

BACKGROUND

The effect of postoperative complications on long-term quality of life (QoL) is controversial in abdominal surgery. This study aimed to investigate the impact of 30-day postoperative complications on long-term QoL after gastrectomy.

METHOD

This is a longitudinal cohort study that enrolled 908 patients undergoing gastrectomy for gastric cancer between 2016 and 2017. QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) generic cancer (QLQ C-30) and gastric module (STO-22) preoperatively and at 1, 6, 12, and 24 months postoperatively. Patients were divided into the morbidity (30-day postoperative complications) and no-morbidity groups, and the postoperative QoL change was compared using a linear mixed model.

RESULTS

The mean age was 62.5 ± 12.0 years. Subtotal and total gastrectomy was performed in 763 (84.0%) and 145 (16.0%) patients, respectively. There were 189 (20.8%) patients developing postoperative complications. The morbidity group showed worse scores in several functions and symptoms of QoL at the baseline. However, the two groups showed no significant difference in postoperative changes in most functions and symptoms of the QLQ C-30 and STO-22 (P_{group × time} > 0.05). The recovery of global health (P_{group × time} < 0.001) and anxiety (P_{group × time} = 0.008) was slightly better in the morbidity group. The subgroup analysis of patients developing major abdominal complications showed similar results.

CONCLUSION

The morbidity group showed worse QoL in several functions and symptoms at the baseline. However, postoperative complications had little influence on QoL change following gastrectomy for gastric cancer.

Acupuncture for Quality of Life in Gastric Cancer Patients Undergoing Adjuvant Chemotherapy

CONTEXT

Patients with gastric cancer experience health-related quality of life (HRQOL) decline during adjuvant chemotherapy following gastrectomy.

OBJECTIVES

This pilot study aimed to evaluate the preliminary effect and feasibility of electro-acupuncture (EA) for HRQOL and symptom burden in these patients.

METHODS

In this open-label, multicenter, parallel controlled trial, gastric cancer patients who planned to receive adjuvant chemotherapy were randomly assigned to receive high-dose EA (seven times each chemotherapy cycle for three cycles), low-dose EA (three times each chemotherapy cycle), or usual care only. The acupoints prescription consisted of bilateral ST36, PC6, SP4, and DU20, EX-HN3, and selected Back-shu points. Patients completed the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) weekly, and the Edmonton Symptom Assessment System (ESAS). The primary outcome was the difference among the groups on the gastric cancer subscale (GaCS) of the FACT-Ga.

RESULTS

Of the 66 randomized patients, 58 were analyzed according to intention-to-treat principle, and 45 were in the per-protocol set (PPS). The average scores in PPS of GaCS were 52.12±9.71, 51.85±12.36, and 45.37±8.61 in high-dose EA, low-dose EA, and control groups, respectively. EA was significantly associated with improved average GaCS scores when compared with control group (51.98±10.91 vs. 45.37±8.61, P = 0.039). EA treatment also produced ESAS relief at the end of intervention (14.36 ± 12.28 vs. 23.91 ± 15.52, P = 0.027). Participants in EA groups had fewer grade ≥3 leukopenia (0% vs. 15.79%, P = 0.031) and neutropenia (2.56% vs. 26.31%, P = 0.012).

CONCLUSION

EA showed promising effects in improving HRQOL, controlling symptom burden, and reducing toxicity during adjuvant chemotherapy in gastric cancer patients. Future adequately powered trials are feasible and needed to confirm the specific effect of EA.

Impact of Body Composition and Physical Function on Quality of Life After Gastrectomy for Gastric Cancer

Purpose

Patients with gastric cancer after gastrectomy often suffer from a decline in their quality of life (QoL), but the relationship between body composition (BC) and physical function on QoL has rarely been studied. This study aims to evaluate and determine the changes in QoL after gastrectomy and the impact of BC and physical function on QoL.

Methods

A total of 311 gastric cancer patients completed EORTC QLQ-C30 and EORTC QLQ-STO22 questionnaires before and 1, 3, 6 months post-surgery. Data including BC, handgrip strength (HGS) and 6-m gait speed (GS) were collected prospectively. Multiple linear regression analysis was used to determine the correlation between QoL and BC, HGS and GS.

Results

Patients had significantly worse scores after surgery on most function and symptom scales (p < 0.001), but most of these scales recovered within 6 months after surgery. A higher subcutaneous fat area (SFA)was associated with increased symptom scores 1 month after surgery. A higher GS is associated with a better global health status symptom.

Conclusion

Patients suffer from a decline in their QoL after gastrectomy for gastric cancer. Intervention strategies aiming at reducing SFA and improving GS may improve the QoL in patients underwent gastrectomy for gastric cancer.

Uncut Roux-en-Y might reduce the rate of reflux gastritis after radical distal gastrectomy: An evidence mapping from a systematic review

BACKGROUND

To evaluate the efficacy, safety, technical feasibility, and effect of reducing the incidence of reflux gastritis from uncut Roux-en-Y (URY) reconstruction after radical distal gastrectomy (RDG) for gastric cancer.

METHODS

A literature search was conducted in PubMed, EMBASE, Web of Science, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang databases until June 30, 2020, to identify studies comparing URY reconstruction with other gastrointestinal tract reconstruction methods after RDG. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration's risk for bias assessment tool were used to assess the risk of bias. The study was performed using review manager RevMan 5.3.0 software.

RESULTS

A total of 35 original studies (six randomized clinical trials (RCTs) and 29 cohort studies) were included in this analysis with a total of 4100 patients. For reflux gastritis, URY anastomosis was significantly superior to the other four types of anastomoses (Billroth-I (odds ratio (OR) = 0.16 [0.10, 0.27], P < 0.00001); Billroth-II (OR = 0.32 [0.20, 0.51], P < 0.00001); Billroth-II with Braun (OR = 0.14 [0.007, 0.26], P < 0.00001), and Roux-en-Y (OR = 0.59 [0.38, 0.91], P = 0.02)). Furthermore, URY anastomosis was better than Billroth-II with Braun (OR = 0.07, 95%confidence interval (CI): [0.02, 0.28], P = 0.0001) and Billroth-II (OR = 0.14, 95%CI: [0.09, 0.24], P < 0.00001) anastomoses for preventing bile reflux. In addition, for anastomotic leakage, URY anastomosis was significantly superior to Roux-en-Y (OR = 0.34, 95%CI: [0.13, 0.87], P = 0.02) anastomosis, and no statistically significant difference between URY and the other three reconstruction methods was found. The postoperative hospital stay of patients receiving URY anastomosis was substantially shorter than those receiving Billroth-II with Braun (MD: 2.84, 95%CI: [-3.16, -1.80], P < 0.00001), Bollroth-II (MD: 1.23, 95%CI: [-2.10, -0.37], P = 0.005) and Roux-en-Y (MD: 1.98, 95%CI: [-2.17, -1.78], P < 0.00001) anastomoses.

CONCLUSION

URY reconstruction significantly reduce the rate of reflux gastritis after RDG, and it was a more favorable reconstruction method after RDG for its operative simplicity, safety, and reduced postoperative complications especially in Roux-en-Y stasis syndrome. Large sample size cohort studies and well-designed RCTs are needed for further confirmation of our findings.

OTHER

This work was supported by the National Nature Science Foundation of China (No.81871962), Industry-University-Research Innovation Fund in the Ministry of Education of the People's Republic of China (No. 2018A01013) and the Autonomous Intelligent Unmanned System (No. 62088101). This study was registered with PROSPERO (CRD42020200906).

Surveillance and Surgical Considerations in Hereditary Diffuse Gastric Cancer

Inactivating germline variants in the CDH1 tumor suppressor gene cause the hereditary diffuse gastric cancer syndrome. Total gastrectomy is recommended for prevention, although it is associated with adverse outcomes and chronic health risks. Gastric cancer surveillance is an alternative to surgery; however, upper gastrointestinal endoscopy is limited by poor sensitivity. Cancer surveillance requires accurate detection of early carcinoma and patient-specific disease penetrance estimates. Current clinical care should incorporate up-to-date information on variable disease penetrance, which does not seem to correlate with CDH1 genotype. Affected patients and families warrant a balanced presentation of options for cancer surveillance and prophylaxis.

Impact of gastric cancer treatment on quality of life of patients

Treatment of gastric cancer is stage specific and ranges from endoscopic resections in early gastric cancer to gastrectomy and multimodal treatment in locally advanced tumour situations. Palliative systemic treatment has the potential to prolong survival in advanced tumour stages. However, tumour-directed therapies and their side-effects potentially worsen the general condition of a patient. Treatment discussions and decisions, especially when trading-off the options with the patient, have widened their focus from 'technical' terms like overall survival, disease-free survival and progression-free survival to patient reported outcomes (PROs) including quality of life (QoL). The assessment of PROs has evolved as important endpoint in clinical studies. A precise definition of QoL seems impossible. Its multiple dimensions can be evaluated by various validated questionnaires like the QLQ-C30 and FACT-G focusing on different priorities. Special additional tools have been developed and validated to assess QoL in gastric cancer patients (QLQ-STO22, FACT-Ga). We herein give an overview on the options to evaluate QoL in patients with gastric cancer and on published data on the impact of tumour-targeted therapy on QoL in these patients.