Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND

Reflux esophagitis is a common postoperative complication of proximal gastrectomy. There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy. We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis (EGAA) can prevent postoperative reflux in a safe and feasible manner.

AIM

To observe a novel method of EGAA to prevent postoperative reflux.

METHODS

Initially, we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis. This was done in order to better understand the anti-reflux function and mechanism. Next, we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy. Post-surgery, we monitored the structure and function of the reconstruction through imaging exams and gastroscopy. Finally, the patients were followed up to assess the efficacy of the anti-reflux effects.

RESULTS

Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma, providing a means to prevent the reverse flow of gastric fluids. Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy, with a mean operation time of 304.2 ± 44.3 min. After the operation, the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux, three had mild reflux, and two had obvious reflux. The abdominal computed tomography examination showed a valve-like structure at the anastomosis. During follow-up, gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients. Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.

CONCLUSION

EGAA is a feasible and safe surgical method, with an excellent anti-reflux effect after proximal gastrectomy.

Various Kinds of Functional Digestive Tract Reconstruction Methods After Proximal Gastrectomy

The incidence of proximal gastric cancer has shown a rising trend in recent years. Surgery is still the main way to cure proximal gastric cancer. Total gastrectomy with D2 lymph node dissection was considered to be the standard procedure for proximal gastric cancer in the past several decades. However, in recent years, many studies have confirmed that proximal gastrectomy can preserve part of the stomach function and can result in a better quality of life of the patient than total gastrectomy. Therefore, proximal gastrectomy is increasingly used in patients with proximal gastric cancer. Unfortunately, there are some concerns after proximal gastrectomy with traditional esophagogastrostomy. For example, the incidence of reflux esophagitis in patients who underwent proximal gastrectomy with traditional esophagogastrostomy is significantly higher than those patients who underwent total gastrectomy. To solve those problems, various functional digestive tract reconstruction methods after proximal gastrectomy have been proposed gradually. In order to provide some help for clinical treatment, in this article, we reviewed relevant literature and new clinical developments to compare various kinds of functional digestive tract reconstruction methods after proximal gastrectomy mainly from perioperative outcomes, postoperative quality of life and survival outcomes aspects. After comparison and discussion, we drew the conclusion that various functional reconstruction methods have their own advantages and disadvantages; large scale high-level clinical studies are needed to choose an ideal reconstruction method in the future. Besides, in clinical practice, surgeons should consider the condition of the patient for individualized selection of the most appropriate reconstruction method.

Jejunal pouch reconstruction after total gastrectomy is associated with better short-term absorption capacity and quality of life in early-stage gastric cancer patients

Background

No consensus exists regarding the best reconstruction style after total gastrectomy (TG). Roux-en-Y oesophagojejunostomy is a simple option for gastrointestinal tract reconstruction. Recently, jejunal pouch reconstruction has been suggested as an appropriate approach. We compared the postoperative outcomes of the two surgical approaches using a well-characterized cohort of gastric carcinoma patients.

Methods

A total of 60 patients who underwent TG were divided into two groups according to the reconstruction style. Both groups were compared regarding patient characteristics, perioperative data and quality of life (QoL), which was assessed using the Spitzer QoL index (QLI) and Visick grade. The incidence of long-term surgery-related complications, including reflux oesophagitis, dumping syndrome, and retention syndrome, was also compared to evaluate postoperative restoration.

Results

Both study groups were comparable with respect to general patient characteristics. No mortality or no significant differences in surgery-related data were found except in the operation time. Compared to Orr Roux-en-Y reconstruction, pouch reconstruction was associated with a longer procedure time, a lower incidence of dumping/retention syndrome and better QoL parameters (p < 0.05).

Conclusion

In this study, jejunal pouch reconstruction after TG was superior to the traditional Roux-n-Y oesophagojejunostomy with respect to improved dietary intake and QoL.

Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis

INTRODUCTION

The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy.

METHODS

Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated.

RESULTS

Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis.

CONCLUSION

Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Phase I Clinical Research of Jejunal Interposition in Adenocarcinoma of the Esophagogastric Junction II/III Proximal Gastrectomy

Objective. To investigate the feasibility and specific methods of single-tract jejunal interposition between esophagus and remnant stomach (ers-STJI) in adenocarcinoma of the esophagogastric junction (AEG) II/III proximal gastrectomy. Methods. 15 AEG II/III gastric cancer (GC) patients in phase T1-3N0M0 with tumor size <5 cm were selected and they underwent proximal gastrectomy with ers-STJI from August 2013 to August 2014. Results. All of the 15 patients successfully completed GC R0 proximal gastrectomy with ers-STJI and no operative death or no significant complication occurred; one patient had anastomotic inflammatory granuloma. The digestive tract reconstruction time was 29.5 ± 5.7 min; the intraoperative blood loss was 96.7 ± 20.2 mL, and the number of lymph node dissections was 21.3 ± 3.0; the postoperative flatus time was 48.2 ± 11.9 h; the average length of hospital stay was 10.7 ± 2.3 d, and the average hospital stay cost was 60 ± 3 thousands. All of the patients were followed up for 12 months, and their postoperative single food intake, body weight, hemoglobin, and albumin were all recovered to the preoperative levels. Conclusions. The applications of ers-STJI in proximal gastrectomy were safe and feasible, and the length of jejunal interposition could be 15-25 cm.

Reconstruction after proximal gastrectomy for gastric cancer in the upper third of the stomach: a review of the literature published from 2000 to 2014

Proximal gastrectomy (PG) is occasionally performed to preserve the physiological function of the remnant stomach with the aim of maintaining a gastric reservoir for patients with early gastric cancer in the upper third of the stomach. Many reconstructive procedures after PG have been reported, including esophagogastrostomy (EG), jejunal interposition, jejunal pouch interposition, and double tract. However, no general agreement exists regarding the optimal reconstructive procedure. This article reviews the current reconstructive procedures available for PG. We examined the surgical outcomes, postoperative complications, endoscopic findings, and quality of life (QOL) according to the reconstructive procedures. We found no significant difference in anastomotic leakage and anastomotic stricture among the procedures. The frequency of reflux esophagitis was higher with simple EG compared with the other reconstructive procedures. Some additional procedures, such as fundoplication, the use of a narrow gastric conduit, and placement of a gastric tube in the lower mediastinum on EG, could decrease the frequency of reflux esophagitis and reflux symptoms. These additional procedures may improve the QOL; however, the previous studies were small and could not adequately compare the reconstructive procedures. Prospective randomized controlled trials that involve a longer trial period and more institutions are needed to clarify the optimal reconstructive procedures after PG.

Comparison of perioperative and long-term outcomes of total and proximal gastrectomy for early gastric cancer: a multi-institutional retrospective study

BACKGROUND

Various surgical procedures are used to treat early gastric cancers in the upper third of the stomach (U-EGCs). However, there is no general agreement regarding the optimal surgical procedure.

METHODS

The medical records of 203 patients with U-EGC were collected from 13 institutions. Surgical procedures were classified as Roux-en-Y esophagojejunostomy after total gastrectomy (TG-RY), esophagogastrostomy after proximal gastrectomy (PG-EG), or jejunal interposition after PG (PG-JI). Patient clinical characteristics and perioperative and long-term outcomes were compared among these three groups.

RESULTS

TG-RY, PG-EG, and PG-JI were performed in 122, 49, and 32 patients, respectively. Tumors were larger in TG-RY patients than in PG-EG and PG-JI patients, and undifferentiated-type gastric adenocarcinoma tended to be more frequent in TG-RY than in PG-EG. The operative time was shorter for PG-EG than for PG-JI and TG-RY. Hospital stay and early postoperative complications were not different for the three procedures. With respect to gastrectomy-associated symptoms, a "stuck feeling" and heartburn tended to be more frequent in PG-EG patients, while dumping syndrome and diarrhea were more frequent in TG-RY patients. Post-surgical weight loss was not different among the three groups, however, serum albumin and hemoglobin levels tended to be lower in TG-RY patients.

CONCLUSION

Three surgical procedures for U-EGC did not result in differences in weight loss, but PG-EG and PG-JI were better than TG-RY according to some nutritional markers. In U-EGC, where patients are expected to have long survival times, PG-EG and PG-JI should be used rather than TG-RY.

Effective palliation and quality of life outcomes in studies of surgery for advanced, non-curative gastric cancer: a systematic review

BACKGROUND

Relief of symptoms should be the primary focus of palliative treatment as defined by the World Health Organization. Evaluating the effectiveness of palliative interventions should incorporate this goal and include quality of life (QOL) outcome assessments. A systematic review of the surgical gastric cancer literature was performed to summarize the effectiveness of palliative surgical interventions in addressing QOL.

METHODS

An electronic literature search of EMBASE, Medline, and the Cochrane Database of Controlled Trials was performed from January 1, 1985 to December 1, 2009. English language abstracts and articles were reviewed independently by two reviewers. A systematic approach to data abstraction and presentation was followed.

RESULTS

No articles were identified as reporting true QOL outcomes using reliable, validated QOL instruments in surgically managed, advanced gastric cancer patients. Nine articles were identified as reporting outcomes measuring effectiveness of palliation. Commonly reported pre-procedure symptoms were weight loss, abdominal pain, vomiting, obstruction, and bleeding. Time to oral intake was reported in 5 of 9 studies, ranging from a mean of 2.9 days (laparoscopic gastrojejunostomy) to 8 days (surgical bypass). Length of postoperative inpatient stay ranged from a mean of 7 days (gastrojejunostomy) to 28 days (surgical bypass). Other measures of effective palliation included measures of clinical success, hospital re-admission rates, and post-procedure analgesic intake.

CONCLUSION

A paucity of literature exists regarding the QOL of surgically managed gastric cancer patients. Prospectively designed studies using credible QOL measures are necessary to better inform the treatment decision-making process for these patients.

The effect of continuous jejunal interposition on gastrointestinal hormones after distal gastrectomy

The objective of our study was to determine the effect of continuous jejunal interposition on gastrointestinal hormones after distal gastrectomy, and lay a foundation for surgical management.Distal subtotal gastrectomy experimental model were established on 24 adult Beagle dogs. Digestive tract reconstruction of the dogs was randomly divided into continuous jejunal interposition group, Billroth II anastomosis group and isolated jejunum interposition group. The content of serum gastrin, plasma motilin and cholecystokinin after different digestive tract reconstructions was detected and compared by enzyme-linked immunosorbent assay. In the dogs which received continuous jejunal interposition, postoperative serum gastrin level was significantly lower than before surgery either in fasting or postprandial state (all p<0.05). The serum gastrin level of continuous jejunal interposition group was significantly higher than the other groups in postprandial state (all p<0.05), and was significantly higher than Billroth II -type anastomosis group in fasting state (p<0.05). Furthermore, the postoperative plasma motilin and cholecystokinin levels were significantly higher than before surgery either in fasting or postprandial in dogs received continuous jejunal interposition (all p<0.05). The postoperative plasma motilin level of continuous jejunal interposition group was significantly higher than the other groups in postprandial state (all p<0.05), and was significantly higher than Billroth II -type anastomosis group in fasting state (p<0.05). However, the postoperative cholecystokinin level of continuous jejunal interposition group was significantly lower than the other groups (all p <0.05).Continuous jejunal interposition after distal gastrectomy could maintain the postoperative plasma motilin and serum gastrin in a relatively high level, while cholecystokinin in a low level.

Measurement and interpretation of patient-reported outcomes in surgery: an opportunity for improvement

BACKGROUND

Surgery may have a profound effect on patients' health-related quality of life (QOL). To be optimally useful, trials that seek to guide clinical decision making should measure outcomes that are important to patients and report the results in a clinically meaningful way. We sought to explore how researchers currently measure and interpret QOL in surgical trials, using gastric cancer as a case study.

METHOD

We performed a systematic review of randomized controlled trials (RCTs) of gastric cancer surgery published between 1966 and 2009 that included at least one patient-reported outcome (PRO). Investigators assessed trial eligibility and extracted data in duplicate using standardized forms, then resolved disagreements by consensus.

RESULTS

Our search identified 87 RCTs of gastric cancer surgery, of which 11 (13%) included at least one PRO. Ten RCTs measured one or more validated PROs, although six also included ad hoc measures. All manuscripts presented the results as raw scores and nine of the 11 trials identified a statistical difference between groups. All 11 manuscripts prominently reported the PRO results in the abstracts and conclusions, but only one discussed the clinical significance of the differences between groups.

CONCLUSIONS

Most RCTs of gastric cancer surgery do not include measures of QOL and those that do suffer from important limitations. RCTs would be more useful to surgeons and patients if authors measured PROs and utilized existing approaches to present the results of PROs in ways that provide an intuitive sense of the magnitude of effects.