Factors affecting the quality of life of patients after gastrectomy as assessed using the newly developed PGSAS-45 scale: A nationwide multi-institutional study

AIM To identify certain clinical factors other than the type of gastrectomy which affect the postoperative quality of life(QOL) of patients after gastrectomy.METHODS The postgastrectomy syndrome assessment scale(PGSAS)-45 was designed to assess the severity of symptoms, the living status and the QOL of gastrectomized patients. It consists of 45 items, of which 22 are original items while 23 were retrieved from the SF-8 and Gastrointestinal Symptoms Rating Scale questionnaires with permission. A nationwide surveillance study to validate PGSAS was conducted and 2368 gastric cancer patients who underwent various types of gastrectomy at 52 medical institutions were enrolled. Of these, 1777 patients who underwent total gastrectomy(TG) reconstructed with Roux-Y(n = 393), distal gastrectomy(DG) reconstructed with Billroth-I(n = 909), or DG reconstructed with Roux-Y(n = 475) were evaluated in the current study. The influence of the type of gastrectomy and other clinical factors such as age, sex, duration after surgery, the symptom severity, the degree of weight loss, dietary intake, and the ability for working on the postoperative QOL(i.e., dissatisfaction for daily life subscale, physical component summary and mental component summary of the SF-8) were examined by multiple regression analysis(MRA). In addition, importance of various symptoms such as esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation and dumping on the postoperative living status and QOL were also appraised by MRA.RESULTS The postoperative QOL were significantly deteriorated in patients who underwent TG compared to those after DG. However, the extent of gastrectomy was not an influential factor on patients' QOL when adjusted by the MRA. Among various clinical factors, the symptom severity, ability for working, and necessity for additional meals were the most influential factorsto the postoperative QOL. As for the individual symptoms, meal-related distress, dumping, abdominal pain, and esophageal reflux significantly affected the postoperative QOL in that order, while the influence of indigestion, diarrhea and constipation was insignificant. CONCLUSION Several clinical factors such as the symptom severity(especially in meal-related distress and dumping), ability for working and necessity for additional meals were the main factors which affected the patients' wellbeing after gastrectomy.

Quality of life after total vs distal gastrectomy with Rouxen-Y reconstruction: Use of the Postgastrectomy Syndrome Assessment Scale-45

AIM To investigate the detrimental impact of loss of reservoir capacity by comparing total gastrectomy(TGRY) and distal gastrectomy with the same Rouxen-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.

Background factors influencing postgastrectomy syndromes after various types of gastrectomy

BACKGROUND Postgastrectomy syndromes(PGS) after curative gastrectomy for gastric cancer are influenced by not only gastrectomy type but also by background factors. Recently, a nationwide PGS study was performed using the Postgastrectomy Syndrome Assessment Scale-45(PGSAS-45) questionnaire.AIM To determine the influence of each background factor on PGS for each gastrectomy type using PGS assessment study(PGSAS) data as an additional analysis. METHODS The data of 2368 patients were obtained from the PGSAS. This included patients undergoing distal gastrectomy(DG) with Billroth I reconstruction, DG with Roux-en-Y reconstruction, total gastrectomy with Roux-en-Y, proximal gastrectomy, pylorus-preserving gastrectomy(PPG), and local resection. Multiple regression analysis was performed to explore the independent effects of each background factor on the main outcome measures(MOMs) of PGSAS-45 for each gastrectomy type. The background factors included postoperative period, age, sex, surgical approach(laparoscopic or open), and the status of the celiac branch of the vagal nerve.RESULTS The MOMs of DG and PPG were highly affected by background factors, whereas those of total gastrectomy with Roux-en-Y, proximal gastrectomy, and local resection were not. Worse PGS were found in females, whereas a longer postoperative period alleviated some of the MOMs. For DG and PPG, a laparoscopic approach and preservation of the celiac branch improved several MOMs.CONCLUSION Various background factors affected PGS, and their influence varied with the type of gastrectomy performed. Laparoscopic surgery and celiac branch preservation can improve PGS in patients undergoing DG and PPG.

Relationship between Nitrogen Atmospheric Deposition, Discharge and Concentration, and Monthly Change of Those in a River

The hypothesis that the product of discharge and concentration of nitrogen (N) in river water is equal to the atmospheric deposition was verified in the mountainous basin of the Tedori River in Japan. To verify this relationship, long-term data?are required to eliminate the effect of short-term variation of the N components. The basin has very high mountains, including Mount Hakusan (2702 maltitude), which is covered with deep snow in winter. Therefore, limited data were used for the estimation of the deposition of the entire basin by assuming a linear relationship of altitude. As a result, it was found that the estimated N concentration coincided well with observed concentrations at six sites—the Shiramine and Kuwajima (upper stream), Nakajima (lower stream) and Dainichi dam, Tedori dam and Senami sites (middle stream). The seasonal variation of N concentrations was low in the snowmelt period and high in autumn through to winter. This was not due to the larger discharge in snowmelt season as it was also found that N deposition was high in winter and low in spring, which indicated a clear relationship between N concentration and monthly atmospheric deposition including N storage in snow pack.

Microstructure and Mechanical Properties of NiTi₂-TiB Composite Fabricated by Spark Plasma Sintering

Composites of NiTi2-TiB have been fabricated using spark plasma sintering and mechanical properties have been investigated. Dense specimens of monolithic NiTi2 have been obtained by the sintering at 950?C. By the x-ray diffraction measurements it has been shown that NiTi2 co-exists with TiB in equilibrium at 950?C. The bending strength of NiTi2-TiB composite increases with increasing the volume fraction of TiB2 up to 60 vol%. The maximum bending strength of 730 MPa has been obtained for NiTi2-60vol% TiB2. The Vickers hardness also increases with increasing the volume fraction of TiB up to 70% and the highest Vickers hardness of 1620 Hv has been obtained for NiTi2-70%TiB.

Quantitative Analysis of the Rate of Geochemical Weathering of Sulfur from Sedimentary Rocks Using Atmospheric Deposition, Concentration and River Discharge Data

Quantitative analysis of the rate of geochemical weathering of sulfur (S) from sedimentary rocks (GeoS) was conducted using concentration (Cs) and discharge (Qs) data from the Tedori River and atmospheric deposition (AtdepS) in the basin. First, S fluxes were calculated using 16 years of Cs and Qs data. The annual average discharge of S (TotalS) was estimated at 8597 ton·year-1 (117.3 kg·ha-1·year-1). Of this, 1331 ton·year-1 was AtdepS (18.2 kg·ha-1·year-1) and another 7266 ton·year-1 was GeoS (99.1 kg·ha-1·year-1). Monthly changes in TotalS were investigated, which showed that GeoS was highest in summer, because of the air temperature, while AtdepS peaked in winter because of seasonal wind. Using Qs and AtdepS corrected for altitude, TotalS, AtdepS and GeoS were estimated at six sites, and among these sites we found that the TotalS per unit area values were random, depending on the site characteristics. In particular, the discharge from the Kuwajima site was remarkably high suggesting that the sedimentary rocks at this site had higher pyrite content than at the other sites. Finally, we also assessed the relationship between the characteristics of sedimentary rocks and GeoS in a range of rivers in the Hokuriku Region, and found that there was a close relationship between concentrations of SO42- greater than 10 mg·l-1 and sedimentary rocks containing the pyrite group. In addition, we estimated that the influence of GeoS was present when the concentration of SO42- in river water was greater than 2 - 3 mg·l-1 in the Hokuriku region.

Long-Term Assessment of Nitrogen Pollution Load Potential for Groundwater by Mass Balance Analysis in the Tedori River Alluvial Fan Area, Japan

To evaluate the nitrogen pollution load in an aquifer, a water and nitrogen balance analysis was conducted over a thirty-five year period at five yearly intervals. First, we established a two-horizon model comprising a channel/soil horizon, and an aquifer horizon, with exchange of water between the aquifer and river. The nitrogen balance was estimated from the product of nitrogen concentration and water flow obtained from the water balance analysis. The aquifer nitrogen balance results were as follows: 1) In the aquifer horizon, the total nitrogen pollution load potential (NPLP) peaked in the period 1981-1990 at 1800 t·yr-1;following this the NPLP rapidly decreased to about 600 t·yr-1 in the period 2006-2010. The largest NPLP input component of 1000 t·yr-1 in the period 1976-1990 was from farmland. Subsequently, farmland NPLP decreased to only 400 t·yr-1 between 2006 and 2010. The second largest input component, 600 t·yr-1, was effluent from wastewater treatment works (WWTWs) in the period 1986-1990;this also decreased markedly to about 100 t·yr-1 between 2006 and 2010;2) The difference between input and output in the aquifer horizon, used as an index of groundwater pollution, peaked in the period 1986-1990 at about 1200 t·yr-1. This gradually decreased to about 200 t·yr-1 by 2006-2010. 3) The temporal change in NPLP coincided with the nitrogen concentration of the rivers in the study area. In addition, nitrogen concentrations in two test wells were 1.0 mg·l-1 at a depth of 150 m and only 0.25 mg·l-1 at 50 m, suggesting gradual percolation of the nitrogen polluted water deeper in the aquifer.

Assessing optimal Roux-en-Y reconstruction technique after total gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND Following a total gastrectomy,patients suffer the most severe form of postgastrectomy syndrome.This is a significant clinical problem as it reduces quality of life(QOL).Roux-en-Y reconstruction,which is regarded as the gold standard for post-total gastrectomy reconstruction,can be performed using various techniques.Although the technique used could affect postoperative QOL,there are no previous reports regarding the same.AIM To investigate the effect of different techniques on postoperative QOL.The data was collected from the registry of the postgastrectomy syndrome assessment study(PGSAS).METHODS In the present study,we analyzed 393 total gastrectomy patients from those enrolled in PGSAS.Patients were divided into groups depending on whether antecolic or retrocolic jejunal elevation was performed,whether the Roux limb was“40 cm”,“shorter”(≤39 cm),or“longer”(≥41 cm),and whether the device used for esophageal and jejunal anastomosis was a circular or linear stapler.Subsequently,we comparatively investigated postoperative QOL of the patients.RESULTS Reconstruction route:Esophageal reflux subscale(SS)occurred significantly less frequently in patients who underwent antecolic reconstruction.Roux limb length:“Shorter”Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS.Anastomosis technique:In terms of esophagojejunostomy techniques,no differences were observed.CONCLUSION The techniques used for total gastrectomy with Roux-en-Y reconstruction significantly affected postoperative symptoms.Our results suggest that elevating the Roux limb,which is not overly long,through an antecolic route may improve patients’QOL.

Defecation disorders are crucial sequelae that impairs the quality of life of patients after conventional gastrectomy

BACKGROUND Defecation disorders are obscure sequelae that occurs after gastrectomy,and its implication on daily lives of patients have not been sufficiently investigated.AIM To examine the features of defecation disorders after gastrectomy and to explore its implication on daily lives of patients in a large cohort using the Postgast rectomy Syndrome Assessment Scale(PGSAS)-45.METHODS We conducted a nationwide multi-institutional study using PGSAS-45 to examine the prevalence of postgastrectomy syndrome and its impact on daily lives of patients after various types of gastrectomy.Data were obtained from 2368 eligible patients at 52 institutions in Japan.Of these,1777 patients who underwent total gastrectomy(TG;n=393)or distal gastrectomy(DG;n=1384)were examined.The severity of defecation disorder symptoms,such as diarrhea and constipation,and their correlation with other postgastrectomy symptoms were examined.The importance of defecation disorder symptoms on the living states and quality of life(QOL)of postgastrectomy patients,and those clinical factors that affect the severity of defecation disorder symptoms were evaluated using multiple regression analysis.RESULTS Among seven symptom subscales of PGSAS-45,the ranking of diarrhea was 4th in TG and 2nd in DG.The ranking of constipation was 5th in TG and 1st in DG.The symptoms that correlated well with diarrhea were dumping and indigestion in both TG and DG;while those with constipation were abdominal pain and mealrelated distress in TG,and were meal-related distress and indigestion in DG.Among five main outcome measures(MOMs)of living status domain,constipation significantly impaired four MOMs,while diarrhea had no effect in TG.Both diarrhea and constipation impaired most of five MOMs in DG.Among six MOMs of QOL domain,diarrhea impaired one MOM,whereas constipation impaired all six MOMs in TG.Both diarrhea and constipation equally impaired all MOMs in DG.Male sex,younger age,division of the celiac branch of vagus nerve,and TG,independently worsened diarrhea,while female sex worsened constipation.CONCLUSION Defecation disorder symptoms,particularly constipation,impair the living status and QOL of patients after gastrectomy;therefore,we should pay attention and adequately treat these relatively modest symptoms to improve postoperative QOL.

Neuroendocrine carcinoma of the esophagus: Report of a case and review of the literature

Esophageal neuroendocrine carcinomas are rare, aggressive and have a poor prognosis. Combined therapy using chemotherapy, radiotherapy and/or surgery appear effective for them. Upper gastrointestinal endoscope of a 65-year-old male revealed a localized ulcerative lesion in the middle esophagus. Histology of biopsy specimens indicated a neuroendocrine carcinoma. A computed tomography showed an esophageal tumor with enlarged mediastinal lymph nodes. The patient was administered neoadjuvant chemo-therapy consisting of 5-fluorouracil and cisplatin, which led to partial response. Subtotal esophagectomy with three-field lymphadenectomy was performed. Pathologically, the tumor was 25 mm and infiltrated the proper muscle layer. The tumor cells were arranged in microtubular structures, with small and round cells containing scanty cytoplasm, and exhibited intense mitosis 51/10 HPF. They were positive for synaptophysin and chromogranin A, and Ki-67 labeling index was 70% - 80%. These findings led to the diagnosis of neuroendocrine carcinoma of small cell type. The patient was administered adjuvant chemotherapy using cisplatin and CPT-11, and he is now alive disease-free at the time of this writing.

Different Magnetic Resonance Imaging Manifestations of Diabetic Chorea in a Case with Hyperglycemia and Another One with Hypoglycemia

Diabetic chorea (DC) is a rare complication of diabetes. Here we describe two cases of DC;patient 1 was an 87-year-old woman with chronic kidney disease and was administered with sulphonylurea and dipeptidylpeptodase-4 inhibitor. She showed right side hemiballismus and head magnetic resonance imaging T1-weighted images revealed a high intensity area in the putamen and caudate nucleus. Patient 2 was a 51-year-old woman who was diagnosed with diabetic ketoacidosis. She showed right side hemiballism and multiple, small hyperintense regions in both the periventricular sides in diffusion weighted images. Based on the hemiballism, we concluded a diagnosis of DC in the diabetic patient, although the case presentation is rare or has atypical MRI findings.