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.

Pathological response measured using virtual microscopic slides for gastric cancer patients who underwent neoadjuvant chemotherapy

BACKGROUND Although pathological response is a common endpoint used to assess the efficacy of neoadjuvant chemotherapy (NAC) for gastric cancer, the problem of a low rate of concordance from evaluations among pathologists remains unresolved. Moreover, there is no globally accepted consensus regarding the optimal evaluation. A previous study based on a clinical trial suggested that pathological response measured using digitally captured virtual microscopic slides predicted patients’ survival well. However, the pathological concordance rate of this approach and its usefulness in clinical practice were unknown. AIM To investigate the prognostic utility of pathological response measured using digital microscopic slides in clinical practice. METHODS We retrospectively evaluated pathological specimens of gastric cancer patients who underwent NAC followed by surgery and achieved R0 resection between March 2009 and May 2015. Residual tumor area and primary tumor beds were measured in one captured image slide, which contained the largest diameter of the resected specimens. We classified patients with < 10% residual tumor relative to the primary tumorous area as responders, and the rest as non-responders;we then compared overall survival (OS) and relapse-free survival (RFS) between these two groups. Next, we compared the prognostic utility of this method using conventional Japanese criteria. RESULTS Fifty-four patients were evaluated. The concordance rate between two evaluators was 96.2%. Median RFS of 25 responders and 29 non-responders was not reached (NR) vs 18.2 mo [hazard ratio (HR)= 0.35, P = 0.023], and median OS was NR vs 40.7 mo (HR = 0.3, P = 0.016), respectively. This prognostic value was statistically significant even after adjustment for age, eastern cooperative oncology group performance status, macroscopic type, reason for NAC, and T- and Nclassification (HR = 0.23, P = 0.018). This result was also observed even in subgroup analyses for different macroscopic types (Borrmann type 4/non-type 4) and histological types (differentiated/undifferentiated). Moreover, the adjusted HR for OS between responders and non-responders was lower in this method than that in the conventional histological evaluation of Japanese Classification of Gastric Carcinoma criteria (0.23 vs 0.39, respectively). CONCLUSION The measurement of pathological response using digitally captured virtual microscopic slides may be useful in clinical practice.

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.

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.

Ⅳ期胃癌转化治疗

Gastric cancer(GC)is one of the most common malignant tumors and represents the fourth most common cause of cancer death worldwide.Surgery is the optimal treatment for patients with GC.However,70%–80%of GC patients are diagnosed at locally advanced stages.A large number of clinical studies have shown that no existing treatment has ideal efficacy against advanced unresectable GC with No.16 lymph nodes or distant organ metastasis,and the median survival time of patients is only approximately 10 months.In recent years,conversion therapy has shown great promise.This approach consists mainly of developing reasonable comprehensive treatment programs,including chemotherapy,radiotherapy,and targeted therapy delivered by a multidisciplinary team(MDT),to convert initially unresectable GC to resectable cancer,thus prolonging patients’survival and improving their quality of life.Here,we aim to discuss the treatment strategies,challenges and opportunities of conversion therapy for GC,along with our experience in conversion therapy for patients with advanced GC(Fig.1).

Pancreaticoduodenectomy for gastric cancer

Pancreaticoduodenectomy(PD)is performed to achieve an R0 resection for gastric cancer with pancreatic and/or duodenal invasion.Several retrospective case series have been published,but the sample cohorts in each study were heterogeneous and small.Moreover,the absence of prospective studies results in a lack of solid evidence that will help determine who can benefit from this procedure.Although the morbidity and mortality of PD have been reported by most studies to be acceptable and that the procedure is feasible,these remained to be much higher than those of standard gastrectomy.Therefore,careful selection of patients should be considered.Based on a review of previous case series and our own experience,PD appears to be beneficial to patients with gastric cancer with pancreatic invasion when R0 resection is possible.In addition,multidisciplinary treatment such as neoadjuvant chemotherapy,is anticipated to improve survival.Nevertheless,considering that prospective randomized studies are difficult to perform,a large-scale multicenter retrospective cohort study is required to evaluate this highly invasive procedure.