Quality of life after total and subtotal gastrectomy for gastric carcinoma

Abstract

Background

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

Method

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

Results

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

Conclusion

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

Introduction

Gastric cancer is the second most common cancer worldwide with an estimated incidence of 870 000¹ per year with nearly two-thirds of cases occurring in developing countries.² In Scotland, the incidence of gastric cancer has decreased by half over the past 23 years from 1985 to 2008 and is more prevalent in the West of Scotland.³

Curative gastrectomy can only be achieved by the complete removal of the tumour with histological confirmation of the tumour free R0 resection margin and associated lymph nodes. Both neo-adjuvant chemotherapy⁴ and D2 lymphadenectomy⁵ can improve survival provided an R0 resection has been completed. Although the position of the tumour will dictate the necessity for TG, there are patients with more distally placed tumours where the value of TG over SG with regard for ‘chance of cure’ versus long term morbidity is unclear provided an adequate lymph node dissection and R0 clearance can be accomplished. Advocates of TG argue that it can be performed safely with low operative mortality and morbidity⁶ while at the same time reduce the risk of incomplete proximal resection margin and eliminate the risk of a second carcinoma in the gastric remnant. However advocates of SG would say that an increase in the risk of mortality and morbidity, reduction in nutritional deficiencies and a worse QoL might be a poor price to pay if TG does not provide any advantage in terms of long-term survival.

There is no doubt that preservation of some proximal stomach appears to be associated with some improvement in gastrointestinal symptoms when compared to TG,⁷ while the use of some form of jejunal pouch after TG does appear to be associated with improved symptoms.⁸

This study was therefore carried out in order to assess the QoL in patients after TG and SG for gastric carcinoma.

All surviving patients who had undergone potentially curative gastrectomy, either SG (including) or TG (without pouch formation), for gastric carcinoma between 1994 and 2009 were identified from a prospectively collected database. SG included some patients undergoing Bilroth I and Bilroth II (for small distal tumours) the majority had Roux-en-Y reconstruction. All patients underwent a D2 lymphadenectomy and in the Bilroth I reconstruction patients the whole lesser curve was resected with the greater curve used for reconstruction. The decision on whether to proceed with TG or SG was left to the decision of the surgeon and was primarily based on findings at operation. These patients were invited to complete two questionnaires provided by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life (QoL) group: the core questionnaire (QLQ-C30 v.3) and the gastric specific module questionnaire (QLQ-STO22).

The EORTC QLQ-C30 comprises 30 items and is composed of 15 scales including global health status and QoL, five functional scales (physical, role, emotional, cognitive and social) and nine symptom scales and single items (fatigue, nausea and vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhoea and financial difficulties).

The EORTC QLQ-STO22 comprises of nine scales including dysphagia, pain, reflux symptoms, eating restrictions, anxiety, dry mouth, taste, body image and hair loss.

The QoL assessment is based on the responder's answers to these questions on a self-completed questionnaire. These raw scores are transformed into linear scores from 0 to 100 as per the EORTC QLQ-30 Scoring Manual and Addendum scoring instructions for the EORTC gastric module QLQ-STO22.

A high score for the global health status and QoL and functional scale from the EORTC QLQ-C30 represents a high QoL. A high score for a symptom scale or single item represents a low QoL. For the EORTC QLQ-STO22 a high score for a scale represents a low QoL.

The results of these scores were entered into a statistical package, the Predictive Analytical SoftWare (PASW) for further analysis. The scored results of the SG and TG groups were analysed using an independent samples t-test and the global health status was analysed with a one way analysis of variance (ANOVA) to compare the difference in QoL between the two procedures.