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Quality ofLife after Upper GI Surgery

GrigoriosChristodoulidis, AthinaA.Samara, andMichelB.Janho

Introduction

The upper part of the gastrointestinal (GI) tract includes the esophagus, stomach and duodenum [1]. Malignant tumors remain the leading cause of upper gastrointestinal surgery, including esophagectomy, gastrectomy or pancreaticoduodenectomy procedures, followed by signicant rates of mortality and morbidity in as many as 40% of patients [2,

3]. The primary goal of oncological upper GI opera-

tions is to achieve a complete tumour resection (R0) and rebuild the digestive tract by creating the appropriate anastomosis [4]. Considering the unique physiological characteristics of the upper part of the GI tract, the increased intraluminal pressures as the rst part of the alimentary tract and the acidic PH of the gastric enzymes, there are signicant rates of anastomotic leakages followed by increased morbidity and adverse events.

Since 1949 when Karnofsky and Burchenal developed a clinical scale to quantify the functional performance of oncological patients, health-related quality of life (HRQL) has been a fundamental concern of oncologic practice [5, 6]. Over the last two decades there has been increased

G. Christodoulidis (*) · A. A. Samara Department of Surgery, University Hospital of Larissa, Larissa, Greece

M. B. Janho Faculty of Medicine, University of Thessaly, Larissa, Greece

interest regarding patient-reported assessment of HRQL treatment effectiveness, which provides a method to capture patients’ perceptions of symptoms, functioning and general well-being after receiving operative treatment [7, 8]. Furthermore, in 2009 the US Food and Drug Administration (FDA) recommended the development and validation of quality-of-life measures (patientreported outcome measures -PROMs) that could be suitable for regulatory purposes [9].

As a traumatic procedure, surgery itself is a major source of stress for surgical patients and directly affects their HRQL [10]. Moreover, postoperative anatomical changes in GI tract structure and function cause specic eating disorders including lack of appetite, reduced functional capacity to eat, reux, nausea, vomiting and malabsorption [11]. Oncological patients with a malignancy located in the upper GI tract, further to the risk of recurrence, experience nutritional consequences that impact HRQL outcomes as a result of signicant postoperative changes in anatomical structures [12]. Selfreported HRQL may represent an important tool in postoperative follow- up, identifying high-risk patients for reduced survival and targeting postoperative functional impairment [13].

In the present chapter, we aim to assess the impact of upper GI surgery on patient reported HRQL, based on available literature reports. An organ-based approach was followed to describe differing impacts on patients’ postoperative quality of life.

https://doi.org/10.1007/978-3-031-27597-5_8

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G. Christodoulidis et al.

Esophagus

Esophageal cancer, Barrett esophagus or severe achalasia are three major esophageal pathologies requiring complex and extensive surgical procedures on the esophagus [14]. Typically, malignancy represents the most common indication for an esophagectomy, which remains the eighth leading cause of cancer-related mortality worldwide [15]. In early-stage esophageal cancer, an esophagectomy can be curative in approximately 30% of patients, and a 5-year overall survival rate of approximately 20% to 40% has been reported [14, 16]. However, esophagectomy remains a surgical procedure associated with a high-risk of severe complications for approximately 40% of patients, in addition to a recurrence rate of 32% to 54% during the rst postoperative year [14, 17].

Esophagectomy can affect health-related quality of life (HRQL) in the immediate postoperative period, with patients experiencing a variety of symptoms within the rst 6 months including fatigue, insomnia, oral dryness, anorexia, dysphagia, reux, esophageal pain, diarrhea, dyspnea, cough and decreased social function [14, 18–20] (Table 8.1). Poor scores in QoL assessed at 6 months after esophagectomy were associated with increased mortality in oncological patients [19, 21]. Postoperative complications including anastomotic leak, infections, cardiopulmonary and operative technical complications contributed to impaired HRQL scores [18, 21–23]. However, according to Rutegard etal. [49], wider oncological surgical operations including the more extensive lymphadenectomy, wider resection margins and a longer operating time are not linked to worse HRQL in the six months following surgery.

Following an esophagectomy patients may benet from periodic assessments of HRQL, to detect increased morbidity based on the patient’s subjective self-reported symptoms. After identication of eligibility for assessment through routine monitoring, the patient can be directed to symptom-specic interventions for better management of their symptoms and improvement of HRQL [14]. However, information regarding

HRQL must be based on well-designed scores and questionnaires to ensure that results are robust and useful for clinical practice [50].

Studies conducted over the last two decades demonstrated that esophagectomy is associated with an impaired HRQL [51]. A systematic review by Scarpa etal. [52] included 21 studies evaluating HRQL using the European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 (14 studies also utilized the disease-specic OES18 or its previous version OES24) [53] and short form-36 (SF-36) [54] questionnaires; this review reported that both short- and long-term HRQL is signicantly affected by esophagectomy for esophageal cancer. The symptom scales indicated worsened fatigue, dyspnea and diarrhea in the 6-month period following esophagectomy; however, emotional function had signicantly improved after the same time period [52]. The impairment of physical function may be a long-term consequence of esophagectomy, involving either the respiratory system or the alimentary tract. Improvement of emotional function in patients who have undergone successful operations may be attributed to the impression that they were cancer survivors [52].

In addition, the well-recognized postoperative deterioration in HRQL after esophagectomy in oncological patients appears to have a long-term impact on patient-reported HRQL. The majority of patients experience significant symptoms for more than 1 year following the esophagectomy, and in some cases individuals reported gastrointestinal symptoms lasting up to 20years after surgery [25,

26]. Long-term survivors of esophageal cancer

surgery experience reduced HRQL in several aspects, with persistence of specific symptoms or event deterioration of these symptoms. The reduction of HRQL appears related not only to older age, but also to the cancer and its treatment [26]. In a pooled-analysis of 15 original studies estimating quality of life among 28 HRQL outcomes, Jacobs etal. [55] concluded that patients experienced long-lasting deterioration in HRQL after esophageal cancer surgery, during a 12-month follow-up period.

8 Quality ofLife after Upper GI Surgery

Compared with the preoperative assessment,

QoL had decreased on discharge from

hospital but was restored within 6months of

operation in disease free patients.

Except for anastomotic strictures, each of the

predened complications (i.e., anastomotic

leak, infections, cardiopulmonary

complications, and operative technical

complications) contributed to decreased

Preoperatively, at

discharge, and 3,6, 9,

12months

postoperatively

6months

postoperatively

HRQL scores

A transthoracic approach, more extensive

lymphadenectomy, wider resection margins

and a longer operating time are not linked to

6months

postoperatively

worse HRQL 6months after surgery.

Assessment of specic HRQL items at

6months can be used as

a predictor of survival.

Patients reporting poor HRQL might

Need intensied clinical attention.

Scores for overall function and global QoL

decline below baseline within 1month after

surgery, and gradually improve but do not

recover fully 6months after surgery.

In the long-term follow-up (6–12months),

adjuvant therapy, eating disorders and

Preoperatively and

6months

postoperatively

Preoperatively, 1 and

6months

postoperatively

Baseline, after

neoadjuvant, and 1, 3,

(continued)

postoperative complications were associated

to poor QoL.

Postoperative HRQL is restored within

6months after discharge. Occurrence of

anastomotic stricture signicantly decreases

HRQL after esophagectomy.

6, 12months

postoperatively

Baseline, at discharge,

1 and 6months after

discharge

Spitzer index

Number

patients QoL instrument Follow up Conclusion regarding QoL

30 QLQ-C30,

QoL pre and post

esophagectomy

prospective

Author Year Study type Comparison

Table 8.1 Including studies regarding HRQL after esophagectomy

Zieren etal. [20] 1996 Cross-sectional

QLQ-OES24

100 QLQ-C30,

QoL post

esophagectomy for

cancer

population-

based

2005 Prospective,

Viklund etal.

[21]

QLQ-OES18

355 QLQ-C30,

QoL post

esophagectomy for

cohort

2008 Prospective

Rutegard etal.

[22]

QLQ-C30,

401

cancer

QoL pre and post

Djarv etal. [19] 2010 Prospective

QLQ-OES18

(614)

esophageal resection,

cardia resection,

extended TG, TG and

cohort

QLQ-OES18

99 QLQ-C30,

oesophageal resection

QoL pre and post

esophagectomy

longitudinal

Chang etal. [18] 2014 Prospective

QLQ-OES18,

and the

IN-PATSAT32

QLQ-OES18

126 QLQ-C30,

QoL pre and post for

cancer

cohort

2014 Prospective

Scarpa etal.

[22]

196 QLQ-C30,

QoL pre and post

esophagectomy for

cancer

cohort

2015 Prospective

Huang etal.

[23]

100

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Long-term survivors of oesophageal cancer

surgery experience reduced HRQL in several

aspects with persistent or even deterioration

in specic symptoms. The HRQL reduction

appears to be not only related to older age,

but also with the cancer and its treatment

Two-thirds of patients experience signicant

symptoms more than 1year after surgery.

5 and 10years

postoperatively

1year postoperatively

(median 4years)

Apart from dysphagia, which improved over

time, esophagectomy was associated with

decreased HRQL and lasting gastrointestinal

symptoms up to 20years after surgery.

Although some symptoms may persist,

1year, 1–5years, and

after 5years

postoperatively

HRQL is similar to that of healthy

individuals.

postoperatively

(2.1–5.4)

Patients who received THE have better

quality of life than those with TTE.

Patients with postoperative adjuvant therapy

only (range

12–48months)

have relatively poor QoL.

Short term HRQL decreased postoperatively

discharge (21-day

median)

G. Christodoulidis et al.

Patient QoL is severely hampered the rst

year after surgery, the lowest being 2months

after surgery.

A signicant decrease in physical function,

role function, and global health score

immediately is observed postoperatively,

followed by slow improvement 18–24 months

afterwards to approach baseline; dysphagia

Baseline and 2, 4, 6,

9, and 12months

postoperatively

Baseline, 3 monthly

for 12months, then

6-monthly until

24months

postoperatively

deteriorated rapidly but improved to baseline

at 9 months.

Number

Table 8.1 (continued)

QLQ-OES18

92 QLQ-C30,

patients QoL instrument Follow up Conclusion regarding QoL

QoL post

esophagectomy for

cancer

cohort

2016 Prospective

Author Year Study type Comparison

Schandl etal.

[24]

QLQ-OG25

876 QLQ-C30 and

QoL post

esophagectomyfor

QLQ-OG25

171 QLQ-C30,

cancer

esophagectomy

cohort

2022 Prospective

Markar etal.

[25]

2022 Case series QoL post

Boshier etal.

[26]

EQ-5D, SF36

QoL post THE 100 SF-36, RSCL 3.5years

cohort

2000 Prospective

De Boer etal.

[27]

110 MOS SF-36 2year postoperatively

THE, extended

esophagectomy (three

eld operation), and

Ivor-Lewis resection

QoL pre and post TTE 30 QLQ-C30 Baseline, and at

cohort

2009 Prospective

Aghajanzadeh

etal. [28]

cohort

2013 Prospective

Tatematsu etal.

[29]

QLQ-OES18

QoL pre and post TTE 79 QLQ-C30,

QoL pre and post MIE 25 QLQ-C30/

cohort

2015 Prospective

Malmström

etal. [30]

2005 Prospective

Leibman etal.

QLQ-OES18

cohort

[31]

8 Quality ofLife after Upper GI Surgery

101

(continued)

MIE leads to a rapid restoration of HRQL.

Baseline, and

6weeks, 3, 6 and

QLQ-OES18

QoL pre and post MIE 62 QLQ-C30,

Worse short-term physical and activity levels

after transthoracic surgery.

No lasting differences in QoL of patients who

12months

postoperatively

5weeks, 3, 6, 9, 12,

18, 24, 30, and

36months

SF-20 and

disease specic

OTE vs. THE 199 RSCL, MOS

underwent either THE or OTE resection were

found. Compared with baseline, QoL declined

after the operation but was restored within a

year in both groups.

Esophageal resections are associated with

signicant deterioration of QoL, which

persists during the follow-up period. The

postoperatively

items

discharge, and

postoperatively, at 3,

105 QLQ-C30 Preoperatively, at

TTE vs. McKeown

esophagectomy

surgical technique and position of the

esophagogastrostomy did not affect QoL

deterioration.

MIE shows an overall benet on HRQL for

the patients on 6months follow-up than open

technique.

Some QoL variables differed signicantly

3months after surgery between THE and

TTE group.

QoL subscales are independent predictors of

survival in potentially curable patients with

6, 12 and 24months

postoperatively

Baseline, and 2, 4, 16,

24weeks

postoperatively

Baseline and

3months

postoperatively

QLQ-OES18

TTE vs MIE 56 QLQ-C30,

RSCL

esophageal adenocarcinoma preoperatively

and postoperatively.

of the scales between the 3 groups.

THE patients do not show signicant

improvement in HRQL except emotional

function. Both techniques show signicant

improvement in dysphagia and eating.

1year postoperatively There were no signicant differences on any

Baseline, and 3, 6, 9,

12months

postoperatively

QLQ-OES18

TTE or THE vs MIE 104 QLQ-C30/

TTE vs THE 55 QLQ-C30,

2010 Prospective

Parameswaran

cohort

etal. [32]

randomized

trial

2004 Comparative

de Boer etal.

[33]

comparative

cohort

2008 Prospective

Egberts etal.

[34]

comparative

cohort

2010 RCT TTE vs THE 199 MOS-SF20,

Wang etal. [35] 2009 Prospective

Van Heijl etal.

[36]

cohort

comparative

cohort

2012 Retrospective

2014 Prospective

Sundaram etal.

[37]

Ramakrishnaiah

etal. [38]

102

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TME can provide better long-term HRQL

outcomes than TTE.

Preoperatively and at

3, 6, 12, 18, and

RAMIE provides a better short-term QoL,

and a better short-term postoperative

functional recovery compared to OTE.

RAMIE is associated with lower immediate

24months

postoperatively

Preopatively, 6weeks

postoperatively

postoperative pain severity and interference.

during inpatient stay,

Surgical technique seems to have little effect

on lasting symptoms and long-term HRQL.

1, and 4months

postoperatively

1year postoperatively

(median 4years)

No clear patient-reported benets of

Preoperatively and at

Th-RAMIE over THE for esophageal cancer.

However, Th-RAMIE conferred several

perioperative benets.

The route of reconstruction had no signicant

impact on patients’ subjective comfort or

QoL.

In the palliative setting retrosternal placement

1, 6, and 12months

postoperatively

G. Christodoulidis et al.

is recommended, as the functional

disadvantages had no impact on QoL.

Number

(continued)

Table 8.1

QLQ-OES18

patients QoL instrument Follow up Conclusion regarding QoL

TTE vs. TME 37 QLQ-C30,

longitudinal

comparative

2019 Prospective

Author Year Study type Comparison

Sugawara etal.

[39]

QLQ-C30,

cohort

2019 RCT OTE vs. RAMIE 112 SF-36,

van der Sluis

etal. [40]

QLQ-OES18,

and EQ-5D

Open vs. RAMIE 170 FACT-E, BPI Preopatively, 3 times

comparative

2019 Prospective

Sarkaria etal.

[41]

cohort

QLQ-OG25

QLQ-OES18

362 QLQ-C30 and

Ivor Lewis vs. TMIE

vs. HMIE vs open

surgery

THE vs Th-RAMIE 309 QLQ-C30/

cohort

comparative

2022 Prospective

Eyck etal. [42] 2022 Prospective

Williams etal.

[43]

26 QLQ-C30 Every 6months

cohort

1999 RCT Retrosternal vs

Gawad etal.

posterior mediastinal

gastric tube

reconstruction

[44]

8 Quality ofLife after Upper GI Surgery

Most QoL aspects deteriorated after radical

surgery for esophageal carcinoma and

regained the preoperative level before the end

of the rst postoperative year. Any major

surgical procedure (three-eld

lymphadenectomy and cervical

esophagogastric anastomosis) gives some

disadvantages in physical, social and role

functioning during the rst six postoperative

months.

Compared with Ivor Lewis and left

transthoracic esophagectomies, combined

thoracoscopic/laparoscopic esophagectomy

and every 3months

for 1year

postoperatively

Preoperatively, and 1,

12, 24weeks

postoperatively

enables higher postoperative QoL, making it a

preferable surgical approach for esophageal

cancer

TTIL is associated with more pain and

constipation than TAMK.

Baseline, then

3-monthly for

12months, 6-monthly

until 24months, and

annually until 5years

postoperatively

The retrosternal route is a better choice for

long term HRQL, although it has a higher risk

of anastomotic leak that might lead to worse

HRQL in early period.

Baseline, 2, and

4weeks, and 3,

6months

postoperatively

103

49 QLQ-C30 Baseline, at discharge,

Ivor-Lewis vs

McKeown

esophagectomy

comparative

cohort

2006 Prospective

Gradauskas

etal. [45]

QLQ-OES18

90 QLQ-C30,

Ivor-Lewis vs. left TTE

vs. combined

thoracoscopic/

laparoscopic

comparative

cohort

Zeng etal. [46] 2012 Prospective

QLQ-OES18

487 QLQ-C30,

esophagectomy

TAMK vs. TTIL

Esophagectomy for

GEJ cancer

comparative

cohort

2017 Prospective

Barbour etal.

[47]

QLQ-OES18

97 QLQ-C30,

MIE prevertebral route

vs. retrosternal route

comparative

cohort

Wang etal. [48] 2010 Prospective

Abbreviations: QLQ-C30: European Organization for Research and Treatment of Cancer Core Quality of Life questionnaire C30, QLQ-OG25/QLQ-OES24/QLQ-OES18:

European Organization for Re-search and Treatment of Cancer Core Quality of Life questionnaire cancer of the oesophagus module, IN-PATSAT32: European Organization for

Research and Treatment of Cancer in-patient satisfaction with care questionnaire, TTE/OTE: Open transthoracic esophagectomy, THE: transhiatal esophagectomy, RAMIE:

Robot-assisted minimally invasive thoracolaparoscopic esophagectomy, GEJ: gastroesophageal junction, TAMK: thoracoscopically assisted McKeown esophagectomy, TTIL:

open transthoracic Ivor Lewis esophagectomy, MIE: Minimally Invasive Esophagectomy FACT-E: Functional Assessment of Cancer Therapy–Esophageal, BPI: Brief Pain

Inventory, TME: Robot-assisted radical Transmediastinal Esophagectomy, SF-36: Short Form-36, EQ-5D: EuroQol 5D, MOS-SF20: Medical Outcome Study Short Form-20,

RSCL: Rotterdam Symptom Checklist, TG: total gastrectomy, PAIS: Psychosocial Adjustment to Illness Scale score, GIQLI: Gastrointestinal Quality of Life Index, Th-RAMIE:

Robotic Transhiatal esophagectomy, TMIE: totally minimally invasive, HMIE: laparoscopy-assisted hybrid minimally invasive

104

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G. Christodoulidis et al.

Postoperative swallowing dysfunction following esophagectomy remains a major cause impairing quality of life, even in disease-free long-term survivors of esophageal cancer [56]. Moreover, esophagectomy for precancerous cases of Barrett syndrome appears to have a similar impact on HRQL when compared to oncological esophagectomies, with a psychological benefit attributed to a reduction in the perceived risk of cancer [57].

Research has shown that postoperative complications delay recovery in terms of poor HRQL from a short-term perspective [58]. However, the impact of postoperative complications on quality of life is long-lasting. According to Derogar etal. [59], major postoperative complications following esophagectomy in oncological patients had a negative impact on HRQL even 5 years after the operation. In the long-term, follow-up factors including adjuvant therapy, eating disorders and postoperative complications were associated with poor HRQL [22]. Specically, although eating dysfunction declined to levels comparable to patients without major postoperative complications, sleep difculties and gastroesophageal reux progressively worsened over time [59].

There are several minimally invasive approaches for esophageal cancer surgery with comparable oncological outcomes to more traditional operations. These different surgical techniques and approaches have also been compared to the more compatible operative techniques in terms of HRQL. A recently published metaanalysis of six original studies [60] concluded that minimally invasive esophagectomy (MIE) has also been associated with a deterioration in HRQL postoperatively. More specically, dyspnea, pain, fatigue, insomnia, constipation, diarrhea, cough, and speech problems increased and a deterioration of global function lasted 6 months; increasing issues related to constipation and speech problems lasted 12months, and insomnia increased more than 12months after MIE [60]. However, according to another pooled analysis by Akhtar etal. [61], MIE was associated with more favorable outcomes than esophagectomy from the perspective of short-term outcomes. Moreover, MIE had signicantly better QLQC-

30 and OES-18 scores compared to esophagectomy in the rst, sixth- and twelve-month follow-up after surgery [62].

Open transthoracic esophagectomy (TTE) is considered the gold standard method for esophagectomy; however, this procedure has been strongly associated with a decrease in HRQL among both the short and long term, with the two rst postoperative months most affected [29, 30]. In this context, TTE was compared with transhiatal esophagectomy (THE) in terms of postoperative quality of life. Data from prospective cohort studies reported that patients who underwent THE had better HRQL results than those who underwent TTE. According to De Boer et al. [27], although some symptoms may persist, the HRQL was similar to that of healthy individuals [28], and no lasting differences were identied between the two operative techniques [33]. Among both TTE and THE groups, HRQL declined when compared with baseline, but was restored within a year after the operation [33]. Conversely, according to a prospective comparative cohort study [38] THE was not associated with a signicant improvement in HRQL, with the exception of emotional function subscales. Furthermore, HRQL values are independent predictors of survival in potentially curable esophageal adenocarcinoma patients, treated with both TTE and THE [36]. Similar to TTE, MIE lead to a postoperative deterioration in HRQL, however MIE is associated with a rapid restoration in the rst three postoperative months [31]. Videoassisted thoracoscopic esophagectomy (VATS) had an overall benet on HRQL for esophageal cancer patients during the 6 month follow-up after esophagectomy, compared with open surgery [32]. In general, MIE shows an overall benet on HRQL for patients at 6 month follow-up, compared to TTE [35].

Results from several studies concluded that surgical technique seems to have little effect on lasting symptoms and long-term HRQL [34, 37,

42–44]. In a retrospective comparative study,

Egberts etal. [34] reported that esophagectomy in general is associated with signicant deterioration of HRQL during a 24-month follow-up period, while both surgical technique and esoph-

8 Quality ofLife after Upper GI Surgery

105

agogastrostomy position did not affect QoL deterioration. Similarly, no signicant difference on any of the HRQL scales were found in patients who underwent TTE, THE or MIE [37]. Furthermore, according to a recently published study [43] there was no clear patient-reported benets of Robotic Transhiatal esophagectomy (Th-RAMIE) over THE for esophageal cancer; however, Th-RAMIE conferred several perioperative benets. The route of reconstruction had no signicant impact on patients’ subjective comfort or quality of life [44].

Alternatively, results of other studies [40, 41,

45–48] found a signicant difference in terms of

HRQL between different techniques and routes of esophagectomy. When comparing Ivor-Lewis and McKeown esophagectomy, three-eld lymphadenectomy and cervical esophagogastric anastomosis leads to some disadvantages in physical, social and role functioning during the rst six postoperative months [45]. Similarly, combined thoracoscopic/laparoscopic esophagectomy was associated with a higher postoperative QoL compared with Ivor Lewis and left transthoracic esophagectomies [46]. Moreover, open transthoracic Ivor Lewis esophagectomy (TTIL) is associated with more pain and constipation than thoracoscopically assisted McKeown esophagectomy (TAMK) in gastroesophageal junction cancer patients [47]. RAMIE was associated with a better short-term quality of life, less postoperative pain and improved short-term postoperative functional recovery compared to TTE [40, 41]. Sugawara et al. [39] concluded that robot-assisted radical transmediastinal esophagectomy was associated with better long-term HRQL compared to TTE.

Gastric

As one of the most common cancers worldwide with more than one million new cases annually, gastric cancer is the second leading cause of cancer- related mortality [63]. Surgery plays a key role in management of gastric cancer patients. Following improvement in terms of survival, long-term impact of HRQL after major gastrec-

tomy has been an area of refocused academic interest [64]. Components of gastric cancer related HRQL impairment include gastrointestinal symptoms, systemic symptoms, global functioning as well as social and psychological health [64]. Despite the durable presence of gastrointestinal symptoms including reux, early satiety, and episodic nausea, global quality of life appears permanently unimpaired following gastrectomy [65]. Gastrectomy is a major operation that alters the physiological functions of the digestive tract and affects patients’ wellbeing. Consequently, patients who undergo this operation commonly experience a broad range of metabolic disorders, including malnutrition and weight loss [66].

The impact of gastrectomy on QoL are obvious and intuitive; however less obvious is the magnitude of any postoperative adverse effects on QoL, the duration of this impaired QoL, and the comparative effects of various surgical options on QoL [67]. Most HRQL scales worsened postoperatively and gradually recovered during the rst postoperative year, with different rates of recovery among the patients [68–71] (Table8.2). Patients who did not survive the rst 2 years may have experienced limited postoperative recovery compared to survivors [68]. Regarding the stage of gastric cancer, according to Kinami etal. [73] the results in terms of HRQL of advanced gastric cancer patients were similar to those of patients with early gastric cancer.

Several different surgical procedures have been described for achieving oncological radicality in gastric cancer [95]. Selection of the appropriate procedure is usually based on tumor location, preoperative staging, the patient’s general physical status and the surgeon’s preference. Nevertheless, patient-reported measures regarding their postoperative physical and emotional state, as opposed to objectively dened shortterm perioperative outcomes, should be taken into consideration to achieve optimal care [95]. Quality of life assessment has become an increasingly important index for evaluating and selecting treatment interventions. Moreover, regarding the exact impact of gastrectomy in terms of HRQL in cases of advanced non-metastatic gastric cancer, a recently published sys-

106

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Potentially curative gastrectomy for cancer

has a detrimental impact on HRQL that

mostly recovers in patients surviving some

2years. Patients who die within 2years may

experience limited postoperative recovery

Most scales worsened after surgery and

gradually recovered afterwards with some

differences in rate of recovery. However, the

scales did not fully recover by 1year period

HRQL reduced in the rst months but

recovers by 12months

Preoperatively, then

6weeks, 3, 6, 9, 12, 18,

and 24months

postoperatively

Preoperatively, 3, 6, 9,

and 12months

postoperatively

Preoperatively, then 1,

3–9, 12, 24months

postoperatively

There were no differences between the

methods used.

14days, then 3, 6,and

After gastrectomy, patients encounter

functional impairments and symptoms, but

12months

postoperatively

Postoperatively (range

1month–5years)

experience only a slightly impaired global

G. Christodoulidis et al.

HRQL.DG, the ability to receive neoadjuvant

treatment, and minimally invasive

gastrectomy may be associated with HRQL

benets.

QoL of patients following advanced gastric

cancer surgery were similar to those of

patients with early gastric cancer.

QoL with respect to the global health status

and functional scales were not signicantly

different between the groups 1year after

surgery.

There were no differences between the

(>1year)

Preoperatively and

1year postoperatively

Every 6months for

methods used.

5years postoperatively

QoL

Number

Table 8.2 Including studies regarding HRQL after gastrectomy

instrument Follow up Conclusion regarding QoL

QLQ-

STO22

patients

Gastrectomy for cancer 58 QLQ-C30,

cohort

2010 Prospective

Authors Year Study type Comparison

Avery etal.

[68]

QLQ-

STO22

272 QLQ-C30,

Open and laparoscopy-

assisted surgery

cohort

2012 Prospective

Kong etal.

[69]

QLQ-

STO22

Gastrectomy for cancer 60 QLQ-C30,

cohort

2014 Prospective

Worster

etal. [70]

QLQ-

STO22

48 QLQ-C30 Preoperatively then,

pouch reconstruction versus

222 QLQ-C30,

gastrectomy without pouch

reconstruction

Gastrectomy vs. reference

population

cross-sectional

2002 RCT Gastrectomy and Longmire’s

Hoksch etal.

[72]

2018 Retrospective

Brenkman

etal. [71]

57 PGSAS-45 Postoperatively

2020 Retrospective Early stages vs. advanced

Kinami etal.

417 QLQ-C30,

stage of gastric cancer

TG or laparoscopy-assisted

2018 Prospective

[73]

Park etal.

QLQ-

STO22

cohort

[74]

quality of

life index

106 Spitzer

interposition vs. TG and

esophagojejunal anastomosis

1995 RCT TG and jejunal pouch

Fuchs etal.

[75]

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