Observational Study Open Access
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2017; 23(11): 2068-2076
Published online Mar 21, 2017. doi: 10.3748/wjg.v23.i11.2068
Quality of life after total vs distal gastrectomy with Roux-en-Y reconstruction: Use of the Postgastrectomy Syndrome Assessment Scale-45
Masazumi Takahashi, Division of Gastroenterological Surgery, Yokohama Municipal Citizen’s Hospital, Yokohama 240-8555, Japan
Masanori Terashima, Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka 411-8777, Japan
Hiroshi Kawahira, Center for Frontier Medical Engineering, Chiba University, Chiba 263-8522, Japan
Eishi Nagai, Department of Surgery and Science, Graduate school of medicine, KyushuUniversity, Fukuoka 812-8582, Japan
Yoshikazu Uenosono, Department of Digestive Surgery, Kagoshima University Graduate School of Medicine, Kagoshima 890-8544, Japan
Shinichi Kinami, Department of Surgical Oncology, Kanazawa Medical School, Kanazawa 920-0265, Japan
Yasuhiro Nagata, Center for Comprehensive Community Care Education, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8523, Japan
Masashi Yoshida, Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
Keishiro Aoyagi, Department of Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan
Yasuhiro Kodera, Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan
Koji Nakada, Department of Laboratory Medicine, The Jikei University School of Medicine, Tokyo 105-8471, Japan
Author contributions: Takahashi M, Terashima M, Kawahira H, Nagai E, Uenosono Y, Kinami S, Nagata Y, Yoshida M, Aoyagi K, Kodera Y, Nakada K collected the data; Nakada K managed the study; Takahashi M wrote the paper; all authors have read and approved the final version to be published.
Supported by a grant from The Jikei University School of Medicine and Japanese Society for Gastro-surgical Pathophysiology.
Institutional review board statement: This study was approved by local ethics committees at each institution.
Informed consent statement: Written informed consent was obtained from all enrolled patients.
Clinical trial registration statement: This study was registered with the University Hospital Medical Information Network’s Clinical Trials Registry (UMIN-CTR; registration number 000002116).
Conflict-of-interest statement: The authors declare no conflicts of interests related to the publication of this study.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Masazumi Takahashi, MD, PhD, Chief, Division of Gastroenterological Surgery, Yokohama Municipal Citizen’s Hospital, 45 Okazawa-cho, Hodogaya-ku, Yokohama 240-8555, Japan. ma06-takahashi@city.yokohama.jp
Telephone: +81-45-3311961 ext. 6330 Fax: +81-45-3311960
Received: December 18, 2016
Peer-review started: December 20, 2016
First decision: February 9, 2017
Revised: February 15, 2017
Accepted: March 2, 2017
Published online: March 21, 2017

Abstract
AIM

To investigate the detrimental impact of loss of reservoir capacity by comparing total gastrectomy (TGRY) and distal gastrectomy with the same Roux-en-Y (DGRY) reconstruction. The study was conducted using an integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45, recently developed by the Japan Postgastrectomy Syndrome Working Party.

METHODS

The PGSAS-45 comprises 8 items from the Short Form-8, 15 from the Gastrointestinal Symptom Rating Scale, and 22 newly selected items. Uni- and multivariate analysis was performed on 868 questionnaires completed by patients who underwent either TGRY (n = 393) or DGRY (n = 475) for stage I gastric cancer (52 institutions). Multivariate analysis weighed of six explanatory variables, including the type of gastrectomy (TGRY/DGRY), interval after surgery, age, gender, surgical approach (laparoscopic/open), and whether the celiac branch of the vagus nerve was preserved/divided on the quality of life (QOL).

RESULTS

The patients who underwent TGRY experienced the poorer QOL compared to DGRY in the 15 of 19 main outcome measures of PGSAS-45. Moreover, multiple regression analysis indicated that the type of gastrectomy, TGRY, most strongly and broadly impaired the postoperative QOL among six explanatory variables.

CONCLUSION

The results of the present study suggested that TGRY had a certain detrimental impact on the postoperative QOL, and the loss of reservoir capacity could be a major cause.

Key Words: Postgastrectomy syndrome, Quality of life, Gastric cancer, Gastrectomy, Patient-reported outcome

Core tip: The influence of postgastrectomy syndrome after total gastrectomy (TG) is believed to be more intense than that after distal gastrectomy (DG). However, the precise features and the degree of interference with quality of life after TG against DG have not been clarified. Then, we weighed DG against TG to determine pure influence of whether presence or absence of remaining stomach (as the reservoir capacity) by employing the same reconstruction route. Moreover, we reinforced the findings by multivariable analysis including other clinical factors, and defined the effect sizes of each variable in the unprecedented examination with large number cases using newly developed Postgastrectomy Syndrome Assessment Scale-45.



INTRODUCTION

The five-year overall survival rate of stage I gastric cancer patients who undergo gastrectomy with sufficient lymphadenectomy has been shown to exceed 90% in Japan[1]. Maintaining quality of life (QOL) after surgery is an important issue for patients who are eventually cured, and several surgical procedures have been developed to minimize the influence of postgastrectomy syndromes (PGS).

The severity of PGS after total gastrectomy (TG) is clinically recognized to be greater than after distal gastrectomy (DG). And a functional analysis has demonstrated the significant interrelationship between weight loss and esophageal bile reflux after TG[2]. Recently, combined questionnaires using the EORTC QLQ-C30 and QLQ-STO22 have demonstrated the differences of several upper-gastrointestinal symptoms associated with distal, proximal and total gastrectomy[3]. However, other study using same combined QOL questionnaires have failed to reveal significant differences in QOL scores[4] among them. Such a discrepancy may have arisen from a lack of adequate instruments for evaluating the QOL in the postgastrectomy patients.

The Japan Postgastrectomy Syndrome Working Party (JPSWP) was founded to more closely investigate the symptoms and lifestyle changes of patients who had undergone gastrectomy. This group collaboratively developed a novel questionnaire [Postgastrectomy Syndrome Assessment Scale (PGSAS)-45] to evaluate the symptoms, living status, and QOL of gastrectomized patients[5]. In this study, we firstly focused the strength and extent of detrimental impact of TG against DG, in which the reservoir capacity is maintained by the remaining stomach, with the same Roux-en-Y reconstruction route, using multi-variate analyses including other clinical factors influencing QOL[6].

MATERIALS AND METHODS
Patients

The following inclusion criteria were applied: (1) a pathologically confirmed diagnosis of stage IA or IB gastric cancer[7]; (2) first-time gastrectomy status; (3) age between ≥ 20 and ≤ 75 years; (4) no history of chemotherapy; (5) no evidence of recurrence or distant metastasis; (6) gastrectomy conducted ≥ 1 year prior to study enrollment; (7) performance status (PS) ≤ 1 on the Eastern Cooperative Oncology Group (ECOG) scale; (8) full ability to understand and respond to the questionnaire; (9) no history of other diseases or surgeries that might influence responses to the questionnaire; (10) absence of organ failure or mental illness; and (11) provision of written informed consent. The exclusion criteria included patients who had an additional malignancy and patients who underwent the concomitant resection of other organs (except for cholecystectomy or splenectomy).

QOL assessment

PGSAS-45 is a newly developed, multidimensional QOL questionnaire (QLQ) consists of a total of 45 questions, with 8 items from the Short-Form Health Survey (SF-8)[8], 15 items from the Gastrointestinal Symptom Rating Scale (GSRS)[9], and 22 clinically important items selected by the JPSWP5. These important items consists of newly selected 10 PGSAS specific items for symptoms (items 24-33), eight questionnaire items pertain to dietary intake (items 34-41), one item for social activity (item 42) and three items about level of satisfaction with daily life (items 43-45). For the 23 symptom items, a seven-grade (1-7) Likert scale was used. A five-grade (1-5) Likert scale was used for all the other items, except for items 1, 4, 29, 32, and 34-37. For items 1-8, 34, 35, and 38-40, higher scores indicate better conditions. For items 9-28, 30, 31, 33, and 41-45, higher scores indicate worse conditions.

Study methods

This study utilized continuous sampling from a central registration system for participant enrollment. The questionnaire was distributed to all eligible patients as they presented at the participating clinics. The patients were instructed to mail the completed questionnaires directly to the data center. All the QOL data from the questionnaires were matched with individual patient data collected via case report forms (CRFs) sent from the physicians in charge of the patients and stored in a database.

This study was registered with the University Hospital Medical Information Network’s Clinical Trials Registry (UMIN-CTR; registration number 000002116). The study was approved by local ethics committees at each institution. Written informed consent was obtained from all the enrolled patients.

PGSAS-45 questionnaires were distributed to 2922 patients between July 2009 and December 2010. Among the 2520 (86%) patients who returned completed questionnaires, 152 were determined to be ineligible because of age (older than 75 years, n = 90), postoperative period > 1 year (n = 29), resection of other organs (n = 8), or other factors (n = 25). The data and responses from the remaining 2368 patients (81%) were eligible for subsequent analyses. In the current study, data from 868 patients who underwent either total gastrectomy (TGRY, n = 393) or distal gastrectomy (DGRY, n = 475), all with Roux-en-Y reconstruction, were retrieved from the database and analyzed. Other data from 1500 patients who underwent distal gastrectomy with Billroth-I reconstruction (DGBI, n = 909), pylorus preserving gastrectomy (PPG, n = 313, proximal gastrectomy (PG, n = 193) or local resection (LR, n = 85) were excluded for this study.

Refinement of the main outcome measures in the PGSAS-45

Based on the data from the completed PGSAS-45 questionnaires, the outcome measures were refined by consolidation and selection[5]. The 23 symptom items were consolidated into the 7 symptom subscales (SS) listed in Table 1. The main outcome measures for the assessment data included several subscales such as the total symptom score, quality of ingestion, level of dissatisfaction for daily life, a physical component summary (PCS) based on items derived from the SF-8, and a mental component summary (MCS), also based on SF-8 items. Each SS score, except the PCS and MCS, was calculated as the mean of the composed items, and the total symptom score was calculated as the mean of seven symptom SSs. In addition, the following parameters were selected as the main outcome measures: body weight changes, amount of food ingested per meal, necessity for additional meals, ability for working, dissatisfaction with symptoms, dissatisfaction at the meals, and dissatisfaction at working.

Table 1 Uni-variate analysis of main outcome measures following total gastrectomy and distal gastrecrtomy procedures.
DomainsSubdomainsMain outcome measuresTGRY
DGRY
Uni-variate analysis
meanSDmeanSDP valueCohen's d
SymptomsPGSAS subscales (GSRS and PGSAS items)Esophageal reflux subscale (items 10, 11, 13, 24)22.01.01.50.7< 0.00010.58
Abdominal pain subscale (items 9, 12, 28)21.80.81.70.80.0571(0.13)
Meal-related distress subscale (items 25-27)22.61.12.10.9< 0.00010.56
Indigestion subscale (items 14-17)22.30.92.00.8< 0.00010.29
Diarrhea subscale (items 19, 20, 22)22.31.22.11.10.0066(0.19)
Constipation subscale (items 18, 21, 23)22.10.92.11.0≥ 0.1
Dumping subscale (items 30, 31, 33)22.31.12.01.0< 0.00010.31
TotalTotal symptom score (above seven subscales)22.20.71.90.7< 0.00010.38
Living statusBody weightChange in body weight-13.8%7.9%-8.9%6.6%< 0.00010.66
Meals(amount)Ingested amount of food per meal6.41.97.22.0< 0.00010.42
Necessity for additional meals2.40.81.90.8< 0.00010.57
Meals (quality)Quality of ingestion subscale1 (items 38-40)23.80.93.80.9≥ 0.1
Social activityAbility for working2.00.91.80.90.00060.24
QOLDissatisfactionDissatisfaction with symptoms2.11.01.80.9< 0.00010.28
Dissatisfaction at the meal2.81.12.21.1< 0.00010.57
Dissatisfaction at working2.11.11.71.0< 0.00010.41
Dissatisfaction for daily life subscale (items 43-45)22.30.91.90.9< 0.00010.51
SF-8Physical component summary (PCS)1 (items 1-8)249.65.650.85.60.00290.21
Mental component summary (MCS)1 (items 1-8)249.26.049.85.70.0974(0.11)
The interpretation of effect sizeCohen's d
(none-very small)(0.20 >)
Small0.20 ≤
Medium0.50 ≤
Large0.80 ≤
Statistical analysis

In comparing patient QOLs after TGRY and DGRY, statistical methods included the t-test and χ2 test. All outcome measures that exhibited significant difference in univariate analysis were further analyzed using multiple regression analysis to eliminate confounding factors by adding time interval from surgery, age, gender, surgical approach, and celiac branch preservation to the type of gastrectomy. P < 0.05 was considered statistically significant. In the case of P < 0.1 by univariate analysis, Cohen’s d was calculated. In the case of that P value of standardized regression coefficient (β) in multiple regression analysis was < 0.1, the β value has shown in the table. Cohen’s d, β, and R2 (coefficient of determination) measure effect sizes. Interpretation of effect sizes were 0.2 < small, 0.5 < medium, and 0.8 < large in Cohen’s d; 0.1 < small, 0.3 < medium, and 0.5 < large in β; and 0.02 < small, 0.13 < medium, and 0.26 < large in R2. StatView software for Windows Ver. 5.0 (SAS Institute Inc.) was used for all statistical analyses.

RESULTS
Patient characteristics

The demographics of all the study participants enrolled from 52 institutions are listed in Table 2. Among the patients who underwent TGRY, the time interval from surgery until the current evaluation and the length of the Roux segment were significantly longer; age, incidence of applying an open approach, extent of lymph node dissection, and combined resection rate were significantly higher; and a posterior route of Roux-en-Y was significantly more common.

Table 2 Patient characteristics.
TGRYDGRYP value
Number of patients393475
Postoperative period(mo)35.0 ± 24.6131.7 ± 18.010.02464
Age63.4 ± 9.2162.0 ± 9.110.02444
GenderMale276318≥ 0.15
Female113154
Preoperative BMI223.0 ± 3.3122.9 ± 3.01≥ 0.14
Postoperative BMI219.8 ± 2.5120.8 ± 2.71< 0.00014
ApproachOpen2933200.01815
Laparoscopic97152
Extent of lymph nodeD0000.01595
dissection3D143
D1a2860
D1b192246
D2164163
Celiac branch of vagal nervePreserved12280.05235
Divided371442
Combined resectionNone246402< 0.00015
Gallbladder8351
spleen522
Miscellaneous42
Length of Roux-en-Y loop(cm)42 ± 4.2132.2 ± 7.11< 0.00014
Route of Roux-en-YAnterior179292< 0.00014
Posterior206175
QOL assessments

PGSAS symptom subscales: Twenty-three symptom items comprising items derived from the GSRS and original items proposed and selected by the participating gastric surgeons during the establishment of the PGSAS were consolidated into seven symptom SSs (i.e., the PGSAS symptom SSs). These SSs reflected the PGS symptom profile and revealed that the patients who underwent TGRY had significantly higher (i.e., worse) scores (Table 1 and Figure 1A). The implication of the type of gastrectomy on each PGSAS symptom SS, in terms of effect size “Cohen’s d”, is shown in Table 1. To eliminate confounding factors, a multiple regression analysis was performed by adding the time interval from surgery, age, gender, surgical approach, and celiac branch preservation as explanatory variables. Cohen’s d (by the univariate analysis) and β (by the multiple regression analysis) of the esophageal reflux SS, meal-related distress SS, indigestion SS and dumping SS were significantly declined by the extent of gastrectomy with medium to small effect size (e.g., Cohen’s d and β, Tables 1 and 3).

Figure 1
Figure 1 Rader charts of Postgastrectomy Syndrome Assessment Scale symptom subscales, life status, and dissatisfactions. A: Twenty-three symptom items consisting of Gastrointestinal Symptom Rating Scale and Postgastrectomy Syndrome Assessment Scale (PGSAS) specific items were consolidated into seven symptom subscales as PGSAS symptom subscales (SS). This radar chart demonstrated the worse conditions of postgastrectomy syndromes (PGS) in total gastrectomy (TGRY) group than that in distal gastrectomy (DGRY) group; B: The radar graph consisting of each score of items related to the life status and the dissatisfactions demonstrated the worse conditions of PGS in TGRY group than that in DGRY group.
Table 3 Multi-variate analysis of main outcome measures.
Main outcome measuresMultiple regression analysis
DomainsSubdomainsType of gastrectomy [TGRY]
Postoperative period (mo)
Age (yr)
Gender [male]
Approach [laparoscopic]
Celiac branch of vagal nerve [preserved]
βP valueβP valueβP valueβP valueβP valueβP valueR2P value
SymptomsSubscales (GSRS and PGSAS items)Esophageal reflux SS20.298< 0.0001≥ 0.1≥ 0.1(-0.079)0.0179(-0.060)0.0828≥ 0.10.096< 0.0001
Abdominal pain SS2(-0.089)0.0096(-0.060)0.0932≥ 0.1-0.181< 0.0001≥ 0.1≥ 0.10.045< 0.0001
Meal-related distress SS20.295< 0.0001≥ 0.1(-0.064)0.0531-0.1140.0006≥ 0.1≥ 0.10.101< 0.0001
Indigestion SS20.166< 0.0001-0.1140.0012≥ 0.1(-0.083)0.0138(-0.071)0.0436(-0.063)0.06390.057< 0.0001
Diarrhea SS20.1070.0020(-0.063)0.0774≥ 0.1(-0.092)0.0074≥ 0.1≥ 0.10.0240.0026
Constipation SS2
Dumping SS20.189< 0.0001≥ 0.1-0.1230.0006-0.1290.0003≥ 0.1≥ 0.10.071< 0.0001
TotalTotal symptom score20.216< 0.0001≥ 0.1> 0.1(-0.092)0.0115≥ 0.1> 0.10.059< 0.0001
Living statusBody weightChange in body weight0.315< 0.0001≥ 0.1(-0.068)0.0449(-0.088)0.0086≥ 0.1≥ 0.10.114< 0.0001
Meals (amount)Ingested amount of food per meal10.202< 0.0001≥ 0.1(-0.060)0.0838> 0.1≥ 0.1≥ 0.10.048< 0.0001
Necessity for additional meals0.273< 0.0001≥ 0.1-0.0830.0142(-0.093)0.0057≥ 0.1≥ 0.10.090< 0.0001
Meals (quality)Quality of ingestion SS1,2
Social activityAbility for working0.1270.0003(-0.079)0.02890.163< 0.0001(-0.073)0.0371≥ 0.1≥ 0.10.052< 0.0001
QOLDissatisfactionDissatisfaction with symptoms0.158< 0.0001(-0.083)0.0199≥ 0.1-0.1050.0022≥ 0.1≥ 0.10.041< 0.0001
Dissatisfaction at the meal0.291< 0.0001(-0.081)0.0193≥ 0.1(-0.072)0.0313≥ 0.1≥ 0.10.093< 0.0001
Dissatisfaction at working0.220< 0.0001≥ 0.1≥ 0.1> 0.1≥ 0.1≥ 0.10.051< 0.0001
Dissatisfaction for daily life SS20.268< 0.0001(-0.086)0.0145≥ 0.1(-0.087)0.0097≥ 0.1≥ 0.10.083< 0.0001
SF-8Physical component summary1,20.1090.0016≥ 0.1-0.1240.0004(-0.079)0.0210≥ 0.1≥ 0.10.034< 0.0001
Mental component summary1,2≥ 0.1≥ 0.1≥ 0.1≥ 0.1≥ 0.1≥ 0.1
The interpretation of effect sizer, βR2
(none-very small)(0.100) >(0.020) >
Small0.100 ≤0.020 ≤
Medium0.300 ≤0.130 ≤
Large0.500 ≤0.260 ≤

The total symptom score, which aggregated all seven PGSAS symptom SSs, denoted the severity of overall PGS symptom and its values of Cohen’s d, β, and R2 in the present study were 0.38, 0.216, and 0.059, respectively. This also indicated that the severity of overall PGS symptom after TGRY were significantly greater than those after DGRY (Tables 1 and 3).

Body weight changes: The body weight change more than one year after gastrectomy was -13.8% in the patients who underwent TGRY and -8.9% in those who underwent DGRY. The type of gastrectomy had a significant and medium implication on body weight loss as to effect size; the uni-variate analysis produced a Cohen’s d of 0.66 (Table 1), and the multiple regression analysis produced a β of 0.315 (Table 3).

Meals, social activity, and dissatisfaction: The ingested amount of food per meal, necessity for additional meals, ability for working, and dissatisfaction with symptoms at the meal and at working were important items included in the PGSAS-45. The scores on these items revealed that the patients who underwent TG experienced significantly worse living status and more dissatisfaction for their lives (Table 1 and Figure 1B).

The Cohen’s d values for the necessity for additional meals, dissatisfaction at the meal and dissatisfaction for daily life SS were of medium effect size. All the other items related to dissatisfaction had small Cohen’s d values, indicating that they were significantly influenced by the type of gastrectomy with small but clinically meaningful effect size (Tables 1 and 3). The dissatisfaction for daily life SS, which consisted of three dissatisfaction items, demonstrated a significant influence of PGS. The Cohen’s d, β, and R2 values for this SS were 0.51, 0.268, and 0.083, respectively (Tables 1 and 3).

SF-8: The SF-8, a useful and simple questionnaire for evaluating generic QOL, includes PCS and MCS as SSs. For the PCS, Cohen’s d was 0.21, and β was 0.109. Thus, the PCS was significantly lower in the TGRY cases (with a small effect size), whereas the MCS did not differ between the TGRY and DGRY cases (Tables 1 and 3).

DISCUSSION

This study aimed to compare the effects of TGRY and DGRY on postoperative QOL in gastric cancer patients. This comparison was performed using the PGSAS-45, a questionnaire developed to measure QOL in postgastrectomy patients. In the series of our cross-sectional study, we found that there was a little difference in the effect after DG between Billroth-I and Roux-en-Y procedure[10]. On the other hand, several clinical factors such as symptom severity, ability for working, and necessity for additional meals had a significant impact on postoperative QOL, while the influence of the extent of gastrectomy was unexpectedly small[6].

The influence of postgastrectomy syndrome is believed to be more intense after TG than after DG. However, the reasons for and degree of interference with QOL after TG vs DG have not been clarified. Most of prior reports compared the postoperative QOL between TG with Roux-en-Y and DG mainly with Billroth-I or II, in which the food or digestive juice passes through the other route[11,12]. Therefore, the detected differences between TG and DG in the previous studies may have designated the aggregated effect of both the preservation of proximal stomach and the reconstruction route. This study compared TGRY with DGRY to determine the pure influence of the remaining stomach (which approximates reservoir capacity).

Our results showed apparent differences in several main outcome measures associated with symptoms, daily living, and QOL. In multivariate analysis, 15 of 19 main outcome measures (with the exception of the constipation SS, indigestion SS, quality of ingestion SS and MCS) indicated significantly inferior conditions in the TGRY group. To identify which outcomes were most declined by the complete loss of reservoir capacity in TGRY, the effect sizes of these main outcome measures were compared. The variables shown to be adversely affected were (in decreasing order of severity) body weight loss, esophageal reflux SS, meal-related distress SS, dissatisfaction with meals, necessity for additional meals, and dissatisfaction with daily life SS. Thus, the PGSAS-45 was able to demonstrate the multifaceted influences on life conditions of total or distal gastrectomy.

Several reports have postulated that preserving the lower esophageal sphincter or cardia prevents esophageal reflux[11,12]. Moreover, esophageal reflux has been less frequently observed following DGRY than after DGBI[8,13-18]. Thus, preserving the proximal stomach with Roux-en-Y reconstruction should help to prevent esophageal reflux. A proximal gastrectomy is regarded as a potent alternative to avoid the serious detrimental impact of TG for early upper-third gastric cancer patients. Indeed, the recent study using the PGSAS-45 questionnaire revealed that proximal gastrectomy appeared to be valuable as a function-preserving procedure, however, declined the majority of symptom SSs such as esophageal reflux, abdominal pain, meal-related distress and ingestion in the same way as TG[19]. Another alternative to avoid the severe impairment of QOL after TG is to constitute the substitute stomach. Although Fein et al[20] and Iivonen et al[21] reported long-term benefits of RY pouch reconstruction after TG, there is no universal consensus regarding the optimal method of reconstruction following TG. A meta-analysis demonstrated several clinical advantages of pouch reconstruction after TG; patients with a pouch reportedly complained significantly less of dumping and heartburn, and they exhibited a significantly better postoperative food intake[22]. Thus, maintaining reservoir function after gastrectomy appears to be of utmost importance.

Further validation of our findings by prospective clinical trials using the PGSAS-45 for assessments at baseline and at various relevant time points is warranted.

Several investigators have assessed QOL following TG and have compared various surgical and reconstructive procedure[22], however, no large-scale QOL comparisons of TG and DG performed with the same reconstruction procedure, Roux-en-Y, have been published to date. The current study has the intrinsic limitation of being a retrospective study. Moreover, the patient-reported outcomes were assessed at a single time point, which could be any time at least one year after surgery. Nevertheless, the postoperative conditions of the patients more than one year after gastrectomy were generally stable[23], and the multivariate analysis identified that the type of gastrectomy (TGRY vs DGRY) was the factor with the greatest influence on several of the main outcome measures. The current study represents the first large-scale investigation of patient QOL following gastrectomy using the PGSAS-45 questionnaire with multivariate analysis.

In this study, the PGSAS-45 defined a certain impairment of QOL after TGRY compared to DGRY specifically. Therefore, it is important to closely monitor patients to enable early detection and management of PGS, and to provide appropriate nutritional support. The results of the present study defined that the sole loss of remaining stomach strongly and broadly impairs the QOL in postgastrectomy patients. This may suggest that reservoir reconstruction using a stomach substitute should be an optional alternative to maintain better QOL after TG.

ACKNOWLEDGMENTS

This study was conducted by the JPGSWP and is registered at UMIN-CTR No. 000002116 as “A study to observe correlation between resection and reconstruction procedures employed for gastric neoplasms and development of postgastrectomy syndrome”. The results of this study were presented at the 2013 International Gastric Cancer Congress in Verona, Italy.

The authors thank all the physicians who participated in this study and the patients whose cooperation made this study possible.

COMMENTS
Background

The influence of postgastrectomy syndrome (PGS) after total gastrectomy (TG) is believed to be more intense than that after distal gastrectomy (DG). However, the precise features and the degree of interference with quality of life (QOL) after TG against DG have not been clarified. It was discussed by a comparison between TG and DG in the past report, however, even if it was the same DG. Most of prior reports compared the postoperative QOL between TG with Roux-en-Y (RY) and DG mainly with Billroth-I (BI) or II (BII), in which the food or digestive juice passes through the other route. Therefore, influence due to the physiological reconstruction might be mixed in the difference of both as well as influence of TG with RY (TGRY).

Research frontiers

Most of prior reports compared the postoperative QOL between TG with RY and DG mainly with BI or BII, in which the food or digestive juice passes through the other route. Several reports have postulated that preserving the lower esophageal sphincter or cardia prevents esophageal reflux. Moreover, esophageal reflux has been less frequently observed following DGRY than after DGBI. Thus, preserving the proximal stomach with Roux-en-Y reconstruction should help to prevent esophageal reflux.

Innovations and breakthroughs

This study was to have compared the DG with TG except influence of the reconstruction course. And we examined influence of the presence or absence of reservoir capacity by multivariable analysis including other clinical factors, and showed the statistical effect sizes. Moreover, this study was unprecedented examination with large number cases and used newly developed PGSAS-45 questionnaire evaluating patient QOL following gastrectomy. The PGSAS-45 defined a certain impairment of QOL after TGRY compared to DGRY specifically. Therefore, it is important to closely monitor patients to enable early detection and management of PGS, and to provide appropriate nutritional support. The results of the present study defined that the sole loss of remaining stomach strongly and broadly impairs the QOL in postgastrectomy patients.

Applications

The study results suggest that reservoir reconstruction using a stomach substitute should be an optional alternative to maintain better QOL after TG.

Terminology

Postgastrectomy syndrome is a group of disorders and complications following gastrectomy. It includes early dumping syndrome, late dumping syndrome, bile reflux gastritis, afferent loop syndrome, efferent loop syndrome, Roux syndrome, postvagotomy diarrhea, malabsorption, anemia, osteoporosis, gastroparesis, and weight loss.

Peer-review

The authors have conducted a well-written study based on sound methods. The manuscript flows easily and with clarity. The case selection and choice of the important variables were appropriate and clinically relevant. The graphs and the tables are to the point and summarizing the main results of the study in an appropriate fashion. The retrospective nature limits the study, and the analysis would benefit from a propensity score matching to match the cases better and hence give stronger inference.

Footnotes

Manuscript source: Invited manuscript

Specialty type: Gastroenterology and hepatology

Country of origin: Japan

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B, B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

P- Reviewer: Bekheit M, Kehagias IG S- Editor: Yu J L- Editor: A E- Editor: Zhang FF

References
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