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8 Quality ofLife after Upper GI Surgery
When STG is clinically feasible, this
procedure has advantages in the early
postoperative period. However, a pouch
reconstruction after TG should be considered
in patients having a favorable tumor status
suggesting a fair chance of long-term
survival.
Overall GIQLI HRQL scores were better in
pouch group.
D1 and D3 patients showed no signicant
differences in QoL.
12months, then yearly
postoperatively
postoperatively
Preoperatively, and
6months, 1year and
annually postoperatively
(5years max)
The laparoscopic approach resulted in
superior short-term outcomes, whereas TG
continued to affect the HRQL in several items
12months after surgery.
Physical functions, functioning roles, social
functions, and several other symptoms
deteriorated to a greater extent in the TG
group than in the STG group.
HRQL deteriorates 3months after
gastrectomy for both methods but recovers
after 6months postoperatively.
Preoperatively and at 1,
3, 6 and 12months
postoperatively
Preoperatively, then 3
and 12months
postoperatively
Preoperatively, then 3, 6,
9, 12, 15, 18, 21, 24, 30,
36, 42months
postoperatively
(continued)
Patients who undergo PG suffer from worse
QoL impairment than patients who undergo
DG or TG.
Preoperatively, then 3, 6,
12, and 18months
postoperatively
107
64 SIP Preoperatively, 3 and
S-shaped reconstruction
1999 RCT TG vs. STG vs. jejunal
Svedlund
etal. [76]
46 GIQLI 6, 12, and 24months
2001 RCT TG and aboral pouch vs TG
Kalmar etal.
index,
Korenaga
etal.
QLQ-
STO22
214 Spitzer
and straight anastomosis
lymphadenectomy vs D3
2008 RCT Gastrectomy + [D1
Wu etal.
[78]
[77]
98 QLQ-C30,
lymphadenectomy]
TG vs. DG vs. laparoscopy
assisted DG
comparative
cohort
2011 Prospective
Kobayashi
etal. [79]
GLG-
STO22
TG vs STG 465 QLQ-C30,
comparative
cohort
2012 Prospective
Kim etal.
[80]
FACT-Ga
TG vs partial gastrectomy 43 FACT-G,
comparative
cohort
2012 Prospective
Munene
etal. [81]
QLQ-
STO22
TG vs DG vs PG 134 QLQ-C30,
comparative
cohort
2013 Prospective
Karanicolas
etal. [82]
108
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QoL after gastric surgery for cancer is
affected by tumor- and treatment-related
factors. To improve patients’ QoL, subtotal
resection with roux-en-Y reconstruction
should be preferred whenever oncologically
acceptable.
Short-term HRQL differences between
81months
postoperatively
(2–300months range)
Preoperatively and
methods no longer becomes valid several
months after surgery.
postoperatively at 3, 6, 9,
12, 18, and 24months
The TG group showed more deterioration in
Preoperatively, then 1, 2,
QoL (pain, reux, eating restriction, and
anxiety) than in the DG group 1year
postoperatively.
There were no differences in HRQL between
3years postoperatively
methods.
Preoperatively, then
6weeks, 3, 6, 9, and
LADG improves HRQL in rst 3months in
12months
postoperatively
Preoperatively then, 7,
comparison to DG.
30, 90days, and yearly
RY compared with BI reconstruction may
postoperatively
contribute signicantly to the reduced
G. Christodoulidis et al.
The BI and R-Y techniques were generally
incidence of reux esophagitis and improved
QoL in patients who undergo R-Y
equivalent in terms of postoperative QoL.
reconstruction.
case had been registered.
Postoperatively only
QoL
Number
of
Table 8.2 (continued)
instrument Follow up Conclusion regarding QoL
QLQ-
STO22
patients
103 QLQ-C30,
TG vs. STG, BII vs. R-Y,
manual reinforcement over
duodenal stump, and
comparative
cohort
2013 Retrospective
Authors Year Study type Comparison
Rausei etal.
[83]
QLQ-
STO22
multi-visceral resection
TG vs. distal STG 275 QLQ-C30,
comparative
cohort
2014 Retrospective
Park etal.
[84]
TG vs PG 586 PGSAS-45 1year after surgery PG provides better HRQL than TG.
2014 Retrospective
Takiguchi
comparative
etal. [85]
TG vs. DG 300 QLQ-C30,
cohort
2020 Prospective
Park etal.
QLQ-
comparative
[84]
STO22
cohort
QLQ-
STO22
2021 RCT TG vs laparoscopic TG 227 QLQ-C30,
Van der Veen
etal. [86]
QLQ-
STO22
164 QLQ-C30,
distal gastrectomy (LADG)
R-Y vs. BI after DG 85 GSRS 1year postoperatively The decreased angle of His in patients after
comparative
study
2008 RCT DG vs laparoscopy-assisted
Kim etal.
2010 Retrospective
[87]
Namikawa
etal. [83]
2012 RCT R-Y vs. BI after DG 332 QLQ-C30 3months after the last
Takiguchi
etal. [88]
8 Quality ofLife after Upper GI Surgery
There were no differences in the
postoperative HRQL between the
reconstructive procedures used.
5days, 3, 6, and
12months
postoperatively
symptoms lower with R-Y.
The best QoL scores were obtained from the
patients who underwent BI.The R-Y method
was better than the Balfour method
6–12months after surgery. However, the
Balfour method was better than the R-Y after
1 year.
and>1year
postoperatively
There were no differences in postoperative
QoL between the methods used
Higher QoL of R-Y is achieved by reducing
the reux related gastritis and pain symptoms,
and promoting a better global health.
after laparoscopic TG is associated with
reduced blood loss and less pain and
6months postoperatively
only
Preoperatively, then
3-monthly until 1year
postoperatively
6months postoperatively The IJOM for digestive tract reconstruction
dysphagia, thus improving QoL after
laparoscopic gastrectomy.
Roux-en-Y reconstruction after subtotal distal
gastrectomy should be preferred over BII
reconstruction.
1–4years
postoperatively, median
3years
109
159 GIQLI Preoperatively, then
Braun after DG
2012 RCT R-Y vs. BI vs. BII with
Lee etal.
[89]
R-Y vs. BI after DG 2922 PGSAS-45 1year postoperatively Weight loss lower with BI.Esophageal reux
2014 Retrospective
Terashima
153 QLQ-C30 6–12months
R-Y vs. BI vs. Balfour after
comparative
cohort
2015 Retrospective
etal. [90]
Smolskas
STG
comparative
etal. [91]
QLQ-
STO22
2017 RCT R-Y vs. BI after DG 118 QLQ-C30,
Hur etal.
[92]
QLQ-
STO22
2017 RCT R-Y vs. BI after DG 140 QLQ-C30,
Yang etal.
[93]
QLQ-
STO22
89 QLQ-C30,
Isoperistaltic anastomosis
(IJOM) vs. R-Y anastomosis
after totally laparoscopic TG
comparative
2017 Retrospective
Huang etal.
[94]
QLQ-
STO22
116 QLQ-C30,
R-Y vs. BII after subtotal
DG.
Subtotal distal vs TG
comparative
2021 Retrospective
Grosek etal.
[95]
Abbreviations: RCT: Randomized Controlled Trial, QLQ-C30: European Organization for Research and Treatment of Cancer Core Quality of Life questionnaire, QLQ-STO22:
European Organization for Research and Treatment of Cancer Core Quality of Life questionnaire gastric cancer module, GIQLI: Gastrointestinal Quality of Life Index, GSRS:
Gastrointestinal Symptom Rating Scale, TG: Total Gastrectomy, SIP: Sickness Impact Prole, STG: subtotal gastrectomy /partial gastrectomy, DG: Distal Gastrectomy, PG:
Proximal gastrectomy, R-Y: Roux-en Y reconstruction, BI: Billroth I, BII: Billroth II, PGSAS-45: Postgastrectomy Syndrome Assessment Scale, FACT-G: The Functional
Assessment of Cancer Therapy scale, FACT-Ga: The Functional Assessment of Cancer Therapy-Gastric
110
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G. Christodoulidis et al.
tematic review [96] concluded that HRQL
deteriorated during the rst 3 months following
resection and chemoradiotherapy. However,
long-term data showed a recovery of HRQL
after 6–12months.
Open gastrectomy (OG) is considered the
treatment of choice for gastric cancer patients;
however, gastrectomy (LG) as a more minimal
laparoscopic approach is rapidly gaining popularity since its inception [97]. Results from randomized controlled trials (RCTs) reported that
there was no clinically relevant difference
between the LG and OG groups regarding HRQL
and nearly all functioning and symptom scales,
up to 12months post-operative [69, 86, 98, 99].
Similar results were reported from a large cohort
study, where QoL with respect to the global
health status and functional scales were not signicantly different between the groups during the
rst postoperative year [74]. Kim etal. [87] compared distal gastrectomy (DG) with laparoscopyassisted distal gastrectomy (LADG) in an RCT
study, concluding that LADG improves HRQL in
the rst 3 months, when compared to DG.In a
prospective comparative study comparing laparoscopic and open distal gastrectomy with open
total gastrectomy, Kobayashi etal. [79] reported
that the laparoscopic approach resulted in superior short-term outcomes, whereas total gastrectomy affects several items of HRQL 12months
after surgery.
Several studies comparing total gastrectomy
(TG), distal gastrectomy (DG), partial gastrectomy (PG) and subtotal gastrectomy (STG) in
terms of HRQL have been published to date [80–
82]. According to Kim etal., [80], physical func-
tions, functioning roles, social functions and
several other symptoms deteriorated to a greater
extent in the TG group, compared to the STG
group. Furthermore, HRQL deteriorates 3 months
after gastrectomy for both TG and PG, but recovers after six postoperative months [81]. In a prospective comparative study, Karanicolas et al.
[82] reported that patients who undergo PG suffered from greater QoL impairment than patients
who underwent DG or TG.Conversely, Takiguchi
etal. [85] in a retrospective study found that PG
provides better HRQL compared to TG.Among
the TG group, pain, reux, eating restriction and
anxiety affected QoL more than in the DG group,
1 year postoperatively [84]. However, differences
in short-term HRQL between TG and STG are
temporary and become insignicant several
months postoperatively [100]. Moreover, regarding the extent of the gastrectomy, an RCT comparing HRQL after D1 and D3 lymphadenectomy
failed to nd a statistically signicant difference
between the two groups [78].
Different reconstructive methods following
gastrectomy have been tested in terms of quality
of life [72, 75–77, 83, 88–95, 101]. Controversial
results have been published related to a pouch
reconstruction after TG.Two smaller sized RCTs
published in the late 1990’s found that there was
no statistically signicant difference in HRQL
among patients with and without a pouch reconstructive method [72, 75]. On the contrary, based
on two other RCTs by Svedlund etal. [76] and
Kalmar et al. [77], pouch reconstruction has
been associated with better HRQL scores, and
should be considered for patients with a favorable tumor status suggesting a fair chance of
long-term survival [76, 77]. Additionally, studies
comparing Roux-en-Y (R-Y) and Billroth reconstruction have been conducted to date with varied results in terms of HRQL [83, 88–93, 95].
The decreased angle of His in patients after RY
compared with Billroth reconstruction may contribute signicantly to the reduced incidence of
reux esophagitis, improved QoL in patients
who undergo R-Y reconstruction and associated
with better HRQL results [83, 95]. On the other
hand, Smolskas etal. [91] reported that the best
QoL scores were obtained from patients who
underwent Billroth I reconstruction. However,
the majority of studies concluded that there was
no difference identied in terms of QoL between
the reconstruction methods used [88, 89, 92].
Moreover, isoperistaltic anastomosis (IJOM) has
been associated with higher HRQL scores than
R-Y anastomosis after totally laparoscopic TG
[94].
8 Quality ofLife after Upper GI Surgery
111
Discussion
An accurate assessment of health-related quality
of life (HRQL) in patients with upper gastroenterological complaints is essential in clinical
decision making, by providing insights into
patients’ experiences of the disease impact and
its treatments on physical, social and emotional
health. This may contribute to an improved
understanding of the long-term impact of treatments, better comparisons of surgical and medical treatment alternatives, and in indications
where no other objective variables exist [101,
102]. Quality-adjusted life years (QALY), an
important tool for health economic evaluations,
can also be calculated from HRQL data [103].
General function, perception of well-being and
Esophageal cancer:
1. In the long-term, follow-up factors including adjuvant therapy,
eating disorders and postoperative complications were associated
2. 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
3. MIE was associated with more favorable outcomes than open
esophagectomy regarding short-term outcomes.
4. Results from several studies concluded that surgical technique
seems to have little effect on lasting symptoms and long-term HRQL
with poor HRQL.
following surgery.
subjective symptoms are the three main domains
utilized in evaluating HRQL of patients with
upper gastrointestinal illness [102, 104].
HRQL reects the patient’s perspective on the
aftermath of a treatment, and more specically,
on the patients’ suffering from gastric and esophageal cancer which are characterized by an unfavorable prognosis [96, 105] (Fig. 8.1). In this
case, an essential cornerstone in decision making
consists of the assessment of HRQL at baseline,
pre- and post-treatment. Regarding the prognostic value of HRQL in esophagogastric cancer, a
major limitation of the current literature is that
most evidence originates from RCTs and
population- based studies, with the former outnumbering the latter [106]. Considering the realworld cancer population is not properly
PROMS:
1. Generic toolsprovide a thorough assessment of
HRQL by offering patients the choice to report on a
range of symptoms, including psychoIogical
manifestations of disease and treatment.
2. Disease and organ specific are valuable in
gleaning information regarding symptomology
commonly experienced by patients with the
3. patients with upper gastrointestinal cancer
frequently present with symptoms related to
eating and drinking. Thus, it is necessary to use a
cancer-specific questionnaire including these
specific condition.
symptoms.
Fig. 8.1 Factors affecting HRQL in esophageal and gastric cancer and factors affecting PROMs
Gastric cancer:
1. Despite the durable presence of gastrointestinal
symptoms including reflux, early satiety, and
episodic nausea, global quailty of Iife appears
permanently unimpaired following gastrectomy
2. Regarding the stage of gastric cancer, the results
in terms of HRQL of advanced gastric cancer
patients were similar to those of patients with
3. There are controversial results from different
studies regarding the impact of different operative
early gastric cancer.
and reconstructive techniques on HRQL.
112
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G. Christodoulidis et al.
represented in RCTs, systematic bias is highly
probable. A typical trial patient reects only a
small percentage of the target population, and
these studies include strict inclusion criteria
[107].
A plethora of generic and disease-specic
PROMs are available for patients scheduled for
upper GI surgery. Generic tools provide a thorough assessment of HRQL by offering patients
the choice to report on a range of symptoms,
including psychological manifestations of disease and treatment [108]. A well-validated and
extensively used generic tool is the 36-Item Short
Form Survey (SF-36) [109]. Furthermore, Patient
Reported Outcomes Measurement Information
System (PROMIS) surveys aimed at globally
assessing physical, mental and social health have
proved to be a well-validated and useful tool for
assessing HRQL in a variety of patient populations [110]. Disease and organ specic tools have
also been used for evaluating HRQL in patients
undergoing upper GI surgery. These scores are
valuable in gleaning information regarding
symptomology commonly experienced by
patients with the specic condition. In addition,
the scores can be used for comparative effectiveness research of different treatment modalities
and potentially for prognostication in malignant
disease [108]. Two of the commonly used
PROMs in oncological patients are the European
Organization for Research and Treatment of
Cancer Quality of Life Questionnaire-Core 30
questionnaire (EORTC QLQ-C30) and the
Functional Assessment of Cancer TherapyGeneral (FACT-G) [111, 112]. The validated
EORTC QLQ-C30 questionnaire is most frequently used in esophagogastric cancer, and this
can be regarded as the ‘standard’ HRQL instrument in esophagogastric cancer RCTs [113].
As with most cancer-specic HRQL questionnaires, patients with upper gastrointestinal cancer
frequently present with symptoms related to eating and drinking. Thus, it is necessary to use a
cancer-specic questionnaire with a site-specic
module [114]. It is worth noting that generic
HRQL tools do not capture these issues, which
then may not be considered. This is clearly evident in several studies where patients report a
decline in general aspects of HRQL after treat-
ment, but a rectication is observed in site specic issues, such as dysphagia [114, 115].
RCT’s focused on HRQL as their primary outcome were more likely to be of better quality
than other studies, which provide their HRQL
ndings alongside the main clinical outcomes
[113, 116, 117]. HRQL studies in the current literature present with inconsistencies among the
standards of HRQL data collection; this is the
product of a paucity of HRQL-specic protocol
content, training and education. Discrepancies of
this magnitude could result in biased HRQL trial
outcomes [118]. Future research should aim to
develop HRQL guidelines and training programs,
focused on supporting researchers to carry out
high-quality data collection.
Considering the fact that the majority of
esophagectomies are performed for lifethreatening conditions, patients’ expectations
focus on survival, without considering other
aspects of HRQL. On the other hand, surgeons
are to be congratulated for lowering operative
mortality and morbidity of these major operations to acceptable levels. However, health professionals should not stand complacent and
neglect working to improve postoperative quality
of life of these patients [119]. HRQOL assessment appears to predict survival better than
clinician- derived performance status and also
appears to be responsive to surgical and nonsurgical therapy [120]. Although the challenges
are many, until we can more consistently optimize postoperative quality of life, a subgroup of
patients (high perioperative risk patients or those
with extensive locally advanced disease that are
associated with poor prognosis may be beneted
the most from a nonsurgical treatment [119].
HRQOL assessment could be a potentially
important adjunct in shared decision-making and
guiding the treatment planning as well as monitoring the progress of treatment [120].
Conclusions (Fig.8.2)
An accurate assessment of health-related quality
of life (HRQL) in patients undergoing upper gastrointestinal surgery is an important prognostic
tool in clinical decision making in this group of
Highlights
8 Quality ofLife after Upper GI Surgery
An accurate assessment of health-related quality of life (HRQL) in patients undergoing upper gastrointestinal (GI) surgery is an important prognostic
tool in clinical decision making in this group of patients.
A plethora of generic and disease-specific patient-reported outcome measures (PROMS) are available for patients scheduled for upper GI surgery.
The generic tool 36-Item Short Form Survey (SF-36) and the European Organization for Research and Treatment of Cancer Quality of Life
Questionnaire-Core 30 questionnaire (EORTC QLQ-C30) in ontological patients are the most commonly used PROMS in upper GI surgery.
Esophagectomy can affect HRQL in the immediate postoperative period, with patients experiencing a variety of symptoms within the first six months
including fatigue, insomnia, oral dryness, anorexia, dysphagia, reflux, esophageal pain, diarrhea, dyspnea, cough and decreased social function.
Poor scores in HRQL assessed at six months after esophagectomy were associated with increased mortality in oncological patients
Postoperative complications delay recovery in terms of poor HRQL from a short-term perspective.
Long-term survivors of esophageal cancer surgery experience reduced HRQL in several aspects, with persistence of specific symptoms or event
deterioration of these symptoms.
Different surgical techniques of esophagectomy seems to have little effect on lasting symptoms and long-term HRQL.
Most HRQL scales worsened following a gastrectomy and gradually recovered during the first postoperative year, with different rates of recovery
among the patients.
Regarding gastrectomy, several studies comparing several operative techniques and reconstructive methods have been published to date with
controversial results.
Fig. 8.2 Highlights
113
patients. Future research should focus on developing HRQL guidelines and training programs,
to carry out high-quality studies which can lead
to improved understanding of this important
postoperative parameter.
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