Observational Study Open Access
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. May 24, 2022; 13(5): 376-387
Published online May 24, 2022. doi: 10.5306/wjco.v13.i5.376
Assessing optimal Roux-en-Y reconstruction technique after total gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45
Masami Ikeda, Masashi Yoshida, Norio Mitsumori, Tsuyoshi Etoh, Chikashi Shibata, Masanori Terashima, Junya Fujita, Kazuaki Tanabe, Nobuhiro Takiguchi, Atsushi Oshio, Koji Nakada
Masami Ikeda, Department of Surgery, Asama General Hospital, Nagano 385-8558, Japan
Masashi Yoshida, Department of Surgery, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
Norio Mitsumori, Department of Surgery, The Jikei University School of Medicine, Tokyo 105-8461, Japan
Tsuyoshi Etoh, Department of Gastroenterological Surgery, Oita University, Oita 879-5593, Japan
Chikashi Shibata, Department of Surgery, Tohoku Medical and Pharmaceutical University, Miyagi 983-8512, Japan
Masanori Terashima, Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, 411-8777, Japan
Junya Fujita, Department of Surgery, Yao Municipal Hospital, Osaka 581-0069, Japan
Kazuaki Tanabe, Department of Gastroenterological and Transplant Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan
Nobuhiro Takiguchi, Department of Gastroenterological Surgery, Chiba Cancer Center, Chiba 260-8717, Japan
Atsushi Oshio, Faculty of Letters, Arts and Sciences, Waseda University, Tokyo 162-8644, Japan
Koji Nakada, Department of Laboratory Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
ORCID number: Masami Ikeda (0000-0002-2947-7705); Masashi Yoshida (0000-0002-5722-0843); Norio Mitsumori (0000-0002-4840-6339); Tsuyoshi Etoh (0000-0003-4093-816X); Chikashi Shibata (0000-0001-8191-4784); Masanori Terashima (0000-0002-2967-8267); Junya Fujita (0000-0002-6379-6750); Kazuaki Tanabe (0000-0002-8650-2735); Nobuhiro Takiguchi (0000-0002-1247-7143); Atsushi Oshio (0000-0002-2936-2916); Koji Nakada (0000-0002-4472-1008).
Author contributions: Ikeda M, Yoshida M, Mitsumori M, Etoh T, Shibata C, Terashima M, Fujita J, Tanabe K, Takiguchi N, Nakada K developed this protocol/project, collected data and performed the research; Oshio A contributed analytical tools; Ikeda M and Nakada K analyzed the data and wrote the manuscript; all authors have read and approve the final manuscript.
Supported by The Jikei University School of Medicine; and Japanese Society for Gastro-surgical Pathophysiology.
Institutional review board statement: The study was approved by the Ethics Committees of all participating institutions.
Informed consent statement: All study participants provided informed written consent prior to study enrollment.
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.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Masami Ikeda, MD, PhD, Chief Doctor, Surgeon, Department of Surgery, Asama General Hospital, 1862-1 Iwamurada, Saku, Nagano 385-8558, Japan. ikedam@tempo.ocn.ne.jp
Received: March 8, 2021
Peer-review started: March 8, 2021
First decision: May 4, 2021
Revised: May 16, 2021
Accepted: April 20, 2022
Article in press: April 20, 2022
Published online: May 24, 2022

Abstract
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.

Key Words: Total gastrectomy, Roux-en-Y, Postgastrectomy syndrome, Quality of life, Postgastrectomy Syndrome Assessment Scale-45

Core Tip: Following a total gastrectomy using various techniques, patients suffer the severe form of postgastrectomy syndrome. We investigated the effect of different techniques in Roux-en-Y reconstruction on postoperative quality of life (QOL) using the Postgastrectomy Syndrome Assessment Scale-45. We analyzed 393 total gastrectomy patients. Esophageal reflux subscale (SS) occurred significantly less frequently in patients who underwent antecolic reconstruction. Shorter Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS. Our results suggest that elevating the Roux limb which is not overly long, through an antecolic route may improve patients’ QOL.



INTRODUCTION

Postgastrectomy syndrome is a serious clinical problem that decreases quality of life (QOL) of patients following gastrectomy[1-5]. As postgastrectomy syndrome is the severest form of the side effect following total gastrectomy[1,2,4,5], reducing the incidence of syndrome should be deliberated while choosing the surgical technique. Post-total gastrectomy Roux-en-Y reconstruction (TGRY) is a simple and robust form of reconstruction performed following a total gastrectomy, and it is widely performed and regarded as the gold standard. As laparoscopic surgery is more widely used in recent years, TGRY techniques have become more diverse now than when open surgery was used[6-12]. Although the differences in techniques appear to affect postoperative QOL, the reasons remain unclear due to lack of sufficient investigation. Therefore, we used Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), which has developed for postgastrectomy evaluation, to investigate how TGRY surgical techniques affect postoperative QOL[13].

MATERIALS AND METHODS
Retrieving the questionnaire

A total of 52 institutions participated in this study. A questionnaire was distributed to 2922 patients between July 2009 and December 2010 (Figure 1). Eligibility criteria for patients were as follows: (1) Diagnosis of pathologically-confirmed stage IA or IB gastric cancer[14]; (2) first-time gastrectomy; (3) aged 20-75 years; (4) no history of chemotherapy; (5) no recurrence or distant metastasis indicated; (6) gastrectomy conducted one or more years prior to the enrollment date; (7) performance status (PS) ≤ 1 on the Eastern Cooperative Oncology Group scale[15-17]; (8) full capacity to understand and respond to the questionnaire; (9) no history of other diseases or surgeries which might influence responses to the questionnaire; (10) absence of organ failure or mental illness; and (11) written informed consent. Patients with dual malignancy or concomitant resection of other organs (with co-resection equivalent to cholecystectomy being the exception) were excluded. Of the distributed questionnaires, 2520 (86%) were retrieved; 152 questionnaires were excluded. A total of 2368 questionnaires were analyzed and it was observed that total gastrectomy was performed in 393 patients; all underwent reconstruction using Roux-en-Y method. Questionnaires of these 393 patients were selected for examination in this study.

Figure 1
Figure 1 Outline of the study. TGRY: Total gastrectomy with Roux-en-Y reconstruction; DGRY: Distal gastrectomy with Roux-en-Y reconstruction; DGBI: Distal gastrectomy with Billroth I reconstruction; PPG: Pylorus-preserving gastrectomy; PG: Proximal gastrectomy; LR: Local resection.
QOL assessment

PGSAS-45 consists of 45 items, including all eight items of the Short Form General Health Survey (SF-8)[18], all 15 items from the Gastrointestinal Symptom Rating Scale[19], and 22 newly-added items that cover various factors reflecting the postgastrectomy patient’s well-being (Table 1)[13].

Table 1 Structure of postgastrectomy syndrome assessment scale 45 (domains/subdomains/items/subscales).
Domains
Subdomains
Items
Subscales
QOLSF-8 (QOL)1 Physical functioning*Physical component summary* (items 1-8)
2 Role physical*
3 Bodily pain*Mental component summary* (items 1-8)
4 General health*
5 Vitality*
6 Social functioning*
7 Role emotional*
8 Mental health*
SymptomsGSRS (symptoms)9 Abdominal painsEsophageal reflux subscale (items 10, 11, 13, 24)
10 Heartburn
11 Acid regurgitation
12 Sucking sensations in the epigastriumAbdominal pain subscale (items 9, 12, 28)
13 Nausea and vomiting
14 BorborygmusMeal-related distress subscale (items 25-27)
15 Abdominal distension
16 EructationIndigestion subscale (items 14-17)
17 Increased flatusDiarrhea subscale (items 19, 20, 22)
18 Decreased passage of stool
19 Increased passage of stoolConstipation subscale (items 18, 21, 23)
20 Loose stool
21 Hard stoolDumping subscale (items 30, 31, 33)
22 Urgent need for defecation
23 Feeling of incomplete evacuationTotal symptom score (above seven subscales)
Symptoms24 Bile regurgitation
25 Sense of food sticking
26 Postprandial fullness
27 Early satiation
28 Lower abdominal pain
29 Number and type of early dumping symptoms
30 Early dumping general symptoms
31 Early dumping abdominal symptoms
32 Number and type of late dumping symptoms
33 Late dumping symptoms
Living statusMeals (amount) 134 Ingested amount of food per meal*Quality of ingestion subscale* (items 38-40)
35 Ingested amount of food per day*
36 Frequency of main meals
37 Frequency of additional meals
Meals (quality)38 Appetite*
39 Hunger feeling*
40 Satiety feeling*
Meals (amount) 241 Necessity for additional meals
Social activity42 Ability to work
QOLDissatisfaction (QOL)43 Dissatisfaction with symptomsDissatisfaction for daily life subscale (items 43-45)
44 Dissatisfaction at the meals
45 Dissatisfaction at working

The following 18 outcome measures were evaluated, each consisting of a single item or an integration of related items from the PGSAS-45: esophageal reflux subscale (SS), abdominal pain SS, meal-related distress SS, indigestion SS, diarrhea SS, constipation SS, dumping SS, total symptom score, ingested amount of food per meal, necessity for additional meals, quality of ingestion SS, ability for working, dissatisfaction with symptoms, dissatisfaction at the meal, dissatisfaction at working and dissatisfaction for daily life SS, and the physical component summary (PCS) and mental component summary (MCS) of SF-8. Percentage changes in body weight (decrease in body weight/preoperative weight) were also determined as an outcome measure. These 19 main outcome measures were scored and classified into three domains: symptoms, living status, and QOL. Higher scores denote better outcomes for the items of PCS, MCS, ingested amount of food per meal, quality of ingestion SS, and changes in body weight, whereas lower scores denote better outcomes for the other 14 outcome measures.

Postoperative follow-up with PGSAS-45

The gastrectomy patients were provided with a PGSAS-45 questionnaire by the surgeon during an outpatient visit. Each patient was asked to complete the questionnaire and mail it to the data center. The clinical data were reported to the data center by the responsible surgeons using case report form and matched to PGSAS-45 responses. All the data were analyzed at the data center. Postgastrectomy daily living was compared among: (1) Elevated route of Roux limb: antecolic vs retrocolic; (2) length of the Roux limb (defined as the distance from esophagojejunostomy to jejunojejunostomy): “shorter (≤ 39 cm)” vs “40 cm” vs “longer (≥ 41 cm)”; and (3) anastomotic procedure for esophagojejunostomy: circular stapler (CS) vs linear stapler (LS) (Figure 2). The study protocol was approved by the institutional review board of each participating institution and registered with the University Hospital Medical Information Network’s Clinical Trials Registry (registration number, 000002116). All patients provided their written informed consent for the confidential use of their information in the data analysis, in compliance with institutional guidelines.

Figure 2
Figure 2 Schema of Roux-en-Y reconstruction after total gastrectomy. a: Route of the Roux limb (antecolic or retrocolic); b: Length of the Roux limb defined as the distance from the esophago-jejunostomy to the jejunojejunostomy [shorter (≤ 39 cm), average (40 cm) or longer (≥ 41 cm)]; c: Anastomotic procedure for esophagojejunostomy (reconstruction using a circular or linear stapler).
Statistics

The values are shown as the mean ± SD. Two-group differences in the mean values were analyzed using an unpaired t-test and multiple-group differences were analyzed using one-way analysis of variance (ANOVA). Tukey multiple comparisons test was used when the ANOVA yielded a P value of < 0.1. Generally, a P value of < 0.05 was considered statistically significant. When the P values were < 0.1 in the t-test or Tukey-test, the effect size (Cohen’s d) was calculated. The value of Cohen’s d reflects the impact of each causal variable: values between 0.2 and < 0.5 denote a small but clinically meaningful difference between the groups; values between 0.5 and < 0.8 denote a medium effect; and values ≥ 0.8 indicate a large effect. All statistical analyses were performed using JMP12.0.1 software (SAS Institute Inc., Cary, NC, United States).

RESULTS
Patient characteristics

Characteristics of the 393 patients are listed in Table 2. The mean age was 63.4 years and the mean postoperative follow-up period was approximately 35 mo. It was observed that the number of male patients was more than the number of female patients and open surgery was more commonly used than laparoscopic surgery. The combined resection of another organ was performed for the gall bladder (83 patients) and spleen (52 patients). Dissection of the lymph node was over D1b in most of the patients. Conversely, celiac branch of the vagus nerve was not preserved in most patients.

Table 2 Patients' characteristics (393 cases are listed).
Characteristics
Values
Number of patients393
Postoperative period (mo), mean ± SD35.0 ± 24.6
Preoperative BMI, mean ± SD23.0 ± 3.3
Postoperative BMI, mean ± SD19.8 ± 2.5
Age, mean ± SD63.4 ± 9.2
Gender (male/female)276/113
Approach (laparoscopic/open)97/293
Extent of lymph node dissection1
D2164
D1b192
D1a28
D14
D1>0
None0
Celiac branch of the vagal nerve (preserved/divided)12/371
Combined resection
Gallbladder83
Spleen52
Miscellaneous2
None246
Route of the Roux limb

The jejunum elevation route during Roux-en-Y reconstruction was described for 385 (98.0%) patients (Table 3). Retrocolic elevation (206 patients) was performed more commonly than antecolic elevation (179 patients). Among the 19 main outcome measures, scores for the esophageal reflux SS were significantly superior in antecolic elevation group compared to retrocolic elevation group with small but clinically meaningful effect (P = 0.028, Cohen’s = 0.23).

Table 3 The effect of the reconstruction route (antecolic or retrocolic) of Roux–limb on postoperative quality of life after total gastrectomy.
Reconstruction route of Roux limbRetro-colica (n = 206)
Ante-colica (n = 179)
P valueCohens d
mean
SD
mean
SD
Esophageal reflux SS2.1 1.11.80.90.0280.229
Abdominal pain SS1.8 0.81.70.8NS
Meal-related distress SS2.7 1.12.61.1NS
Indigestion SS2.3 0.982.30.9NS
Diarrhea SS2.4 1.32.21.1NS
Constipation SS2.1 1.02.00.8NS
Dumping SS2.4 1.12.31.1NS
Total symptom score2.2 0.82.10.7NS
Change in Body weight-13.6%7.8%-14.0%8.1%NS
Ingested amount of food per meal6.5 1.96.41.8NS
Necessity for additional meals2.3 0.82.40.7NS
Quality of ingestion SS3.7 1.03.80.9NS
Ability to work2.1 0.92.00.8NS
Dissatisfaction with symptoms2.1 1.02.01.0NS
Dissatisfaction at the meal2.8 1.12.81.1NS
Dissatisfaction at working2.1 1.12.21.0NS
Dissatisfaction for daily life SS2.4 0.92.30.9NS
Physical component summary49.2 5.850.15.4NS
Mental component summary49.1 6.149.25.9NS
Length of the Roux limb

Of the 393 patients, the length of the Roux limb was described in 373 (94.9%) patients (Table 4). The most common Roux limb length was “40 cm” (238 patients), followed by “longer (≥ 41 cm)” (119 patients) and “shorter (≤ 39 cm)” (16 patients) Roux limb length (Figure 3). “Shorter” Roux limb length had not worsen the esophageal reflux SS, and rather reduced the indigestion SS compared to both the “40 cm” and “longer” Roux limb groups with medium effect size in terms of Cohen’s d values (shorter vs 40 cm: P = 0.020, Cohen’s d = 0.69; “shorter” vs “longer”: P = 0.030, Cohen’s d = 0.68, respectively). In addition, “shorter” Roux limb attenuated abdominal pain SS with marginal significance (P = 0.081).

Figure 3
Figure 3 The distribution of the length of Roux-limb after total gastrectomy. N/A: Not answered group indicated.
Table 4 The effect of the length of Roux-limb (shorter, 40 cm, longer) on postoperative quality of life after total gastrectomy.
Length of Roux limbShorter (n = 16)
40 cm (n = 238)
Longer (n = 119)
ANOVA
Multiple comparisonsP valueCohens d
mean
SD
mean
SD
mean
SD
P value
Esophageal reflux SS1.8 0.92.01.12.01.0NS
Abdominal pain SS1.4 0.41.80.81.70.70.081Shorter vs 40 cm0.0530.52
Meal-related distress SS2.2 0.92.71.22.71.0NS
Indigestion SS1.7 0.72.30.92.30.90.026Shorter vs 40 cm0.0200.69
Shorter vs longer0.0300.68
Diarrhea SS2.0 1.22.31.22.31.2NS
Constipation SS2.3 0.92.10.92.10.9NS
Dumping SS1.8 0.92.41.12.31.1NS
Total symptom score1.9 0.62.20.82.20.7NS
Change in Body weight-14.1%8.6%-13.8%8.2%-13.5%7.5%NS
Ingested amount of food per meal5.5 2.66.41.96.51.7NS
Necessity for additional meals2.4 0.82.40.82.30.7NS
Quality of ingestion SS3.3 1.23.80.93.81.0NS
Ability to work2.4 1.22.00.92.10.9NS
Dissatisfaction with symptoms1.8 1.02.01.12.21.0NS
Dissatisfaction at the meal3.3 1.22.81.22.81.0NS
Dissatisfaction at working2.5 1.32.21.12.11.0NS
Dissatisfaction for daily life SS2.5 1.02.30.92.40.8NS
Physical component summary49.2 6.749.45.750.15.5NS
Mental component summary48.1 5.948.76.349.95.5NS
Anastomotic procedure for esophagojejunostomy

Of the 393 patients, the device used for anastomosis between the esophagus and jejunum was described in 388 (98.7%) patients (Table 5). The CS was used in 348 patients, while the LS was used in 40 patients. Among the 19 main outcome measures of PGSAS-45, there was no difference between the two procedures.

Table 5 The effect of anastomotic procedure for esophagojejunostomy (circular stapler, linear stapler) on postoperative quality of life after total gastrectomy.
Anastomotic methodCircular stapler(n = 348)
Liner stapler (n = 40)
P value
mean
SD
mean
SD
Esophageal reflux SS2.0 1.0 1.9 0.8 NS
Abdominal pain SS1.8 0.8 1.7 0.8 NS
Meal-related distress SS2.6 1.1 2.8 1.2 NS
Indigestion SS2.3 0.9 2.2 0.8 NS
Diarrhea SS2.3 1.2 2.2 1.3 NS
Constipation SS2.1 0.9 2.1 1.0 NS
Dumping SS2.3 1.1 2.4 1.1 NS
Total symptom score2.2 0.7 2.1 0.7 NS
Change in Body weight-13.9%7.9%-12.8%7.9%NS
Ingested amount of food per meal6.5 1.9 6.2 1.8 NS
Necessity for additional meals2.3 0.8 2.4 0.8 NS
Quality of ingestion SS3.8 1.0 3.8 0.9 NS
Ability to work2.0 0.9 2.1 0.9 NS
Dissatisfaction with symptoms2.1 1.0 2.1 0.9 NS
Dissatisfaction at the meal2.8 1.1 3.0 1.0 NS
Dissatisfaction at working2.1 1.1 2.2 1.0 NS
Dissatisfaction for daily life SS2.3 0.9 2.5 0.8 NS
Physical component summary49.6 5.7 50.2 4.9 NS
Mental component summary49.2 6.0 49.2 5.9 NS
DISCUSSION

Postgastrectomy syndrome is the severest following total gastrectomy and persists in the long-term; thereby, lowering patients’ QOL[1,2,4,5]. Therefore improvement of surgical techniques to reduce the onset of this syndrome is important. TGRY is a simple and robust technique that is performed widely and regarded as the gold standard for post-total gastrectomy reconstruction. While the increased use of laparoscopic surgery and anastomotic devices has resulted in the diversification of TGRY surgical techniques[6-12], the effects of different TGRY techniques on patients’ QOL remains unknown. Our results indicate that elevation of the Roux limb via antecolic route resulted in fewer esophageal reflux SS, and the relatively “shorter” Roux limb length accompanied by fewer indigestion SS without increasing esophageal reflux SS. In terms of device selection for esophagojejunostomy, no difference was observed between the CS and LS procedures. To the best of our knowledge, this is the first report to demonstrate that differences in surgical techniques in TGRY affect postoperative QOL.

The Roux limb reconstruction in TGRY has often been performed via retrocolic route in open surgeries, as it applies slight tension to the anastomosis due to the short distance to the esophageal stump. With the increased use of laparoscopic surgery, surgeons began elevating the Roux limb via antecolic route due to its technical simplicity[7]. And then, the antecolic elevation became more common even for open total gastrectomy. Our investigation into the effects of different Roux limb reconstruction routes in TGRY on postoperative QOL indicate that esophageal reflux SS was significantly attenuated in the antecolic route group than the retrocolic route group. One of the possible explanation is that in the antecolic reconstruction, duodenal fluid hardly flow back into the esophagus unless it passes over the height of the transverse colon when the patient took the lying-down position. As a result, this physical barrier of gravity could attenuate the esophageal reflux SS in addition to the preventive effect of the peristalsis of the Roux limb. Based on these, the antecolic route may be a suitable surgical procedure when performing TGRY. Although the caution is needed for the occurrence of the internal hernia through Petersen’s defect especially when the gastrectomy underwent laparoscopically, and the implementing preventive methods such as the closure of these defects with sutures[20,21] should be performed.

Many surgeons concern that the insufficient length of Roux limb likely to increase the esophageal regurgitation. However, in the present study, the esophageal reflux SS did not worsened in the “shorter” Roux limb length group compared to the other groups, therefore, even relatively short Roux limbs of 30-35 cm may have produced the sufficient intestinal peristalsis to prevent esophageal regurgitation. Interestingly, significantly more indigestion SS was observed in the “40 cm” and “longer” Roux limb length groups compared to the “shorter” group. This may be, in part, explained by the previous report[22] showing that relatively long Roux limbs could be a cause of Roux-en-Y syndrome. The Roux limb length should be adjusted as an appropriate length, and not too long[22].

Although esophagojejunostomy in TGRY had mainly performed using the CS, the increase in laparoscopic surgery has resulted in the diversification of anastomotic techniques and the esophagojejunostomy using the LS is increasing[9-11]. Comparison of the CS and LS procedures in terms of the effect of the esophagojejunostomy technique on postoperative QOL revealed no differences in any of the main outcome measures of PGSAS-45, therefore, either of the CS or LS procedures can be selected depending on the clinical situation to achieve a safe and simple anastomosis procedure.

Many surgeons had chosen the retrocolic route as that of the Roux limb from the problems concerned with the distance of Roux limb and occurrence of internal hernia, and enough length of the Roux limb preventing the regurgitation to esophagus. The result of this PGSAS study may provide a hint for the optimal surgical procedures after total gastrectomy. A limitation of the present study is its retrospective nature and the unbalanced number of patients in each group. A well-designed prospective study should be conducted in the future.

CONCLUSION

Our results revealed that the specific surgical technique used for TGRY affects postoperative QOL to some extent. Since postgastrectomy syndrome is the severest following total gastrectomy, a technique that could maintain a favorable postoperative QOL should be selected. The findings of this study suggest that some of the postgastrectomy symptoms following TGRY could be attenuated by elevating Roux limb through antecolic route with not too long Roux limb length.

ARTICLE HIGHLIGHTS
Research background

Following a total gastrectomy using various techniques, some patients suffer the severe form of postgastrectomy syndrome.

Research motivation

Although the differences in techniques of Roux-en-Y reconstruction appear to affect postoperative quality of life (QOL), the reasons remain unclear due to lack of sufficient investigation.

Research objectives

We investigated the effect of different techniques on postoperative QOL.

Research methods

Using the Postgastrectomy Syndrome Assessment Scale-45, we investigated the effect of different techniques in Roux-en-Y reconstruction on postoperative QOL. We analyzed 393 total gastrectomy patients.

Research results

Esophageal reflux subscale (SS) occurred significantly less frequently in patients who underwent antecolic reconstruction. Shorter Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS.

Research conclusions

Our results suggest that elevating the Roux limb which is not overly long, through an antecolic route may attenuate some of the postgastrectomy symptoms.

Research perspectives

Patients’ QOL after total gastrectomy may be improved by this study.

ACKNOWLEDGEMENTS

The authors thank all the physicians who participated in this study and the patients whose cooperation made this study possible. This study was completed by 52 institutions in Japan. The contributor of each institution is listed below. Masanori Terashima (Shizuoka Cancer Center), Junya Fujita (Sakai City Medical Center), Kazuaki Tanabe (Hiroshima University), Nobuhiro Takiguchi (Chiba Cancer Center), Masazumi Takahashi (Yokohama Municipal Citizen’s Hospital), Kazunari Misawa (Aichi Cancer Center Hospital), Koji Nakada (The Jikei University School of Medicine), Norio Mitsumori (The Jikei University School of Medicine), Hiroshi Kawahira (Graduate School of Medicine, Chiba University), Tsutomu Namikawa (Kochi Medical School), Takao Inada (Tochigi Cancer Center), Hiroshi Okabe (Kyoto University Graduate School of Medicine), Takashi Urushihara (Hiroshima Prefectural Hospital), Yoshiyuki Kawashima (Saitama Cancer Center), Norimasa Fukushima (Yamagata Prefectural Central Hospital), Yasuhiro Kodera (Nagoya University Graduate School of Medicine), Takeyoshi Yumiba (Osaka Kosei-Nenkin Hospital), Hideo Matsumoto (Kawasaki Medical School), Akinori Takagane (Hakodate Goryoukaku Hospital), Chikara Kunisaki (Yokohama City University Medical Center), Ryoji Fukushima (Teikyo University School of Medicine), Hiroshi Yabusaki (Niigata Cancer Center Hospital), Akiyoshi Seshimo (Tokyo Women’s Medical University), Naoki Hiki (Cancer Institute Hospital), Keisuke Koeda (Iwate Medical University), Mikihiro Kano (JA Hiroshima General Hospital), Yoichi Nakamura (Toho University Ohashi Medical Center), Makoto Yamada (Gifu Municipal Hospital), SangWoong Lee (Osaka Medical College), Shinnosuke Tanaka (Fukuoka University School of Medicine), Akira Miki (Kobe City Medical Center General Hospital), Masami Ikeda (Yokosuka General Hospital Uwamachi), Satoshi Inagawa (University of Tsukuba), Shugo Ueda (Kitano Hospital), Takayuki Nobuoka (Sapporo Medical University School of Medicine), Manabu Ohta (Hamamatsu University school of Medicine), Yoshiaki Iwasaki (Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital), Nobuyuki Uchida (Haramachi Redcross Hospital), Eishi Nagai (Graduate School of Medical Sciences, Kyushu University), Yoshikazu Uenosono (Kagoshima University Graduate School of Medicine), Shinichi Kinami (Kanazawa Medical University), Yasuhiro Nagata (National Hospital Organization Nagasaki Medical Center), Masashi Yoshida (International University of Health and Welfare, Mita Hospital), Keishiro Aoyagi (School of Medicine Kurume University), Shuichi Ota (Osaka Saiseikai Noe hospital), Hiroaki Hata (National Hospital Organization, Kyoto Medical Center), Hiroshi Noro (Otemae Hospital), Kentaro Yamaguchi (Tokyo Women’s Medical University Medical Center East), Hiroshi Yajima (The Jikei University Kashiwa Hospital), Toshikatsu Nitta (Shiroyama Hospital), Tsuyoshi Etoh (Oita University), Chikashi Shibata (Tohoku University Graduate School of Medicine), Atsushi Oshio (Waseda University).

Footnotes

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Japan Surgical Society, No. 0229736; The Japanese Society of Gastroenterological Surgery, No. G0085947; Japanese Gastric Cancer Association, No. 5787; The Japanese Society for Gastro-surgical Pathophysiology; and Japanese Society of Clinical Surgeons, No. 1184.

Specialty type: Surgery

Country/Territory of origin: Japan

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Tharavej C S-Editor: Gong ZM L-Editor: A P-Editor: Gong ZM

References
1.  Karanicolas PJ, Graham D, Gönen M, Strong VE, Brennan MF, Coit DG. Quality of life after gastrectomy for adenocarcinoma: a prospective cohort study. Ann Surg. 2013;257:1039-1046.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 96]  [Cited by in F6Publishing: 101]  [Article Influence: 10.7]  [Reference Citation Analysis (0)]
2.  Lee JH, Lee HJ, Choi YS, Kim TH, Huh YJ, Suh YS, Kong SH, Yang HK. Postoperative Quality of Life after Total Gastrectomy Compared with Partial Gastrectomy: Longitudinal Evaluation by European Organization for Research and Treatment of Cancer-OG25 and STO22. J Gastric Cancer. 2016;16:230-239.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 13]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
3.  Rausei S, Mangano A, Galli F, Rovera F, Boni L, Dionigi G, Dionigi R. Quality of life after gastrectomy for cancer evaluated via the EORTC QLQ-C30 and QLQ-STO22 questionnaires: surgical considerations from the analysis of 103 patients. Int J Surg. 2013;11 Suppl 1:S104-S109.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 24]  [Article Influence: 3.1]  [Reference Citation Analysis (0)]
4.  Takiguchi N, Takahashi M, Ikeda M, Inagawa S, Ueda S, Nobuoka T, Ota M, Iwasaki Y, Uchida N, Kodera Y, Nakada K. Long-term quality-of-life comparison of total gastrectomy and proximal gastrectomy by postgastrectomy syndrome assessment scale (PGSAS-45): a nationwide multi-institutional study. Gastric Cancer. 2015;18:407-416.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 114]  [Cited by in F6Publishing: 127]  [Article Influence: 14.3]  [Reference Citation Analysis (0)]
5.  Tanizawa Y, Tanabe K, Kawahira H, Fujita J, Takiguchi N, Takahashi M, Ito Y, Mitsumori N, Namikawa T, Oshio A, Nakada K; Japan Postgastrectomy Syndrome Working Party. Specific Features of Dumping Syndrome after Various Types of Gastrectomy as Assessed by a Newly Developed Integrated Questionnaire, the PGSAS-45. Dig Surg. 2016;33:94-103.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Hirahara N, Monma H, Shimojo Y, Matsubara T, Hyakudomi R, Yano S, Tanaka T. Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy. World J Surg Oncol. 2011;9:55.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 18]  [Cited by in F6Publishing: 20]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
7.  Hosoya Y, Lefor A, Ui T, Haruta H, Kurashina K, Saito S, Zuiki T, Sata N, Yasuda Y. Internal hernia after laparoscopic gastric resection with antecolic Roux-en-Y reconstruction for gastric cancer. Surg Endosc. 2011;25:3400-3404.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 26]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
8.  Zhao YL, Su CY, Li TF, Qian F, Luo HX, Yu PW. Novel method for esophagojejunal anastomosis after laparoscopic total gastrectomy: semi-end-to-end anastomosis. World J Gastroenterol. 2014;20:13556-13562.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 5]  [Cited by in F6Publishing: 4]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
9.  Kitagami H, Morimoto M, Nakamura K, Watanabe T, Kurashima Y, Nonoyama K, Watanabe K, Fujihata S, Yasuda A, Yamamoto M, Shimizu Y, Tanaka M. Technique of Roux-en-Y reconstruction using overlap method after laparoscopic total gastrectomy for gastric cancer: 100 consecutively successful cases. Surg Endosc. 2016;30:4086-4091.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 26]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
10.  Huang ZN, Huang CM, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Lu J, Chen QY, Cao LL, Lin M, Tu RH, Lin JL. Digestive tract reconstruction using isoperistaltic jejunum-later-cut overlap method after totally laparoscopic total gastrectomy for gastric cancer: Short-term outcomes and impact on quality of life. World J Gastroenterol. 2017;23:7129-7138.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 15]  [Cited by in F6Publishing: 15]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
11.  Gong CS, Kim BS, Kim HS. Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: A single-center experience. World J Gastroenterol. 2017;23:8553-8561.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 36]  [Cited by in F6Publishing: 37]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
12.  Norero E, Muñoz R, Ceroni M, Manzor M, Crovari F, Gabrielli M. Two-Layer Hand-Sewn Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy for Gastric Cancer. J Gastric Cancer. 2017;17:267-276.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 12]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
13.  Nakada K, Ikeda M, Takahashi M, Kinami S, Yoshida M, Uenosono Y, Kawashima Y, Oshio A, Suzukamo Y, Terashima M, Kodera Y. Characteristics and clinical relevance of postgastrectomy syndrome assessment scale (PGSAS)-45: newly developed integrated questionnaires for assessment of living status and quality of life in postgastrectomy patients. Gastric Cancer. 2015;18:147-158.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 76]  [Cited by in F6Publishing: 66]  [Article Influence: 9.5]  [Reference Citation Analysis (0)]
14.  Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011;14:113-123.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1698]  [Cited by in F6Publishing: 1665]  [Article Influence: 154.4]  [Reference Citation Analysis (0)]
15.  Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC, Kaasa S, Klee M, Osoba D, Razavi D, Rofe PB, Schraub S, Sneeuw K, Sullivan M, Takeda F. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85:365-376.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9529]  [Cited by in F6Publishing: 10019]  [Article Influence: 328.6]  [Reference Citation Analysis (0)]
16.  Sprangers MA, Cull A, Groenvold M, Bjordal K, Blazeby J, Aaronson NK. The European Organization for Research and Treatment of Cancer approach to developing questionnaire modules: an update and overview. EORTC Quality of Life Study Group. Qual Life Res. 1998;7:291-300.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 67]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
17.  Kaasa S, Bjordal K, Aaronson NK, Moum T, Wist E, Hagen S, Kvikstad A. The EORTC core quality of life questionnaire (QLQ-C30): validity and reliability when analysed with patients treated with palliative radiotherapy. Eur J Cancer. 1995;31A:2260-2263.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 218]  [Cited by in F6Publishing: 219]  [Article Influence: 8.1]  [Reference Citation Analysis (0)]
18.  Turner-Bowker DM, Bayliss MS, Ware JE Jr, Kosinski M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Qual Life Res. 2003;12:1003-1012.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 234]  [Cited by in F6Publishing: 245]  [Article Influence: 13.0]  [Reference Citation Analysis (0)]
19.  Svedlund J, Sjödin I, Dotevall G. GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Dig Dis Sci. 1988;33:129-134.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 857]  [Cited by in F6Publishing: 639]  [Article Influence: 25.2]  [Reference Citation Analysis (0)]
20.  Kimura H, Ishikawa M, Nabae T, Matsunaga T, Murakami S, Kawamoto M, Kamimura T, Uchiyama A. Internal hernia after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer. Asian J Surg. 2017;40:203-209.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 23]  [Cited by in F6Publishing: 24]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
21.  Ojima T, Nakamori M, Nakamura M, Katsuda M, Hayata K, Kato T, Tsuji T, Yamaue H. Internal Hernia After Laparoscopic Total Gastrectomy for Gastric Cancer. Surg Laparosc Endosc Percutan Tech. 2017;27:470-473.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 19]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
22.  Gustavsson S, Ilstrup DM, Morrison P, Kelly KA. Roux-Y stasis syndrome after gastrectomy. Am J Surg. 1988;155:490-494.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 148]  [Cited by in F6Publishing: 160]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]