Br. J. Surg. 1992, Vol. 79, March,
248-250
D. Korenaga, H. Orita, T. Okuyama, S. Moriguchi, Y. Maehara and K. Sugimachi Department of Surgery 11, Faculty of Medicine, Kyushu University, Fukuoka 812, Japan Correspondence to: Dr D. Korenaga
Quality of life after gastrectomy in patients w i t h carcinoma of the stomach One hundred and jifty patients without recurrence of disease after R, gastrectomy f o r carcinoma of the stomach were interviewed to determine their quality of life after surgery. Patients ate less and weighed less but most appeared to be well adjusted and had an optimistic attitude regarding their physical state. There was no evidence of a diminished quality of life in those who had undergone distal partial gastrectomy. These patients had a higher overall food tolerance, body-weight and performance status compared with those treated by total gastrectomy. Considering the satisfactory outcome and the sustained quality of life, radical R, gastrectomy may be the treatment of choice f o r carcinoma of the stomach.
Extensive l y m p h node dissection and c o m b i n e d resection of involved organs gives a significant prolongation of survival for Such patients with gastric cancer treated by curative en bloc o p e r a t i o n s h a v e a greater m a r g i n of safety, t h e operative - ~ . patients with mortality rate being less t h a n 5 per ~ e n t ~ Since carcinoma of the s t o m a c h a r e surviving for longer periods of time m o r e attention should be directed t o t h e relief of s y m p t o m s and t o t h e quality of life. T h e quality of life of patients w h o have undergone surgery for c a r c i n o m a of the o e s o p h a g ~ s *or~ ~ or repair of a b d o m i n a l a o r t i c a n e u r y s m ' h a s been discussed. Little is k n o w n of the results following radical surgery for gastric cancer. In this study, food tolerance, body-weight a n d performance s t a t u s were determined i n patients with no recurrence of disease after R, gastrectomy for carcinoma. T h e objective of t h e study was t o clarify whether t h e operative procedure was justified in terms of t h e quality of life in such patients after operation.
Patients and methods Pu/ienfs One hundred and fifty patients with carcinoma of the stomach who had undergone R, gastrectomy between 1969 and 1987 were studied. All were in good clinical condition without recurrence of disease when the survey was carried out in 1989. Clinical data are shown in Tahk 1 ; 83 patients had undergone distal partial gastrectomy and 67 total gast rect omy . Surqicul prowdures
R, gastrectomy had been performed as described by the Japanese Research Society for Gastric Cancer'. The entire greater omentum, superior leaf of the mesocolon, pancreatic capsule and lesser omentum had been removed en bloc with the stomach. When the tumour had involved the middle or lower third of the stomach, a distal partial gastrectomy had been performed with dissection of the perigastric nodes along lesser and greater curvatures and those in the right paracardial, suprapyloric and infrapyloric regions. Extragastric nodes, such as those along the left gastric, splenic, coeliac and common hepatic arteries, had also been dissected. The left gastric artery had been ligated and divided at its origin. When the tumour had been located in the upper third of the stomach total gastrectomy had been carried out. Lymphadenectomy in the left paracardial region had also been performed. In general, splenectomy had not proven necessary in patients with early gastric carcinoma. Reconstructive surgery had used an intestinal loop brought up to the lower oesophagus through an antecolic route. Oesophagojejunostomy had been performed in an end-to-side fashion. An enteroenterostomy had been constructed about 35-40 cm distant from the oesophagojejunostomy.
Table 1 Purim/ derails No. of patients Age (years) < 59 2 60 Sex ratio ( M : F ) Type of surgery Distal gastrectomy Billroth 1 Billroth I1 Total gastrectomy With splenectomy Without splenectomy Stage of disease* I I1 111 1v Time after operation (years) 1-3 3-6 6- 10
> 10 Total
89 61 97:53 43 40 34 33 67 27 46 10 33 32 31 54 150
*Japanese staging system
status and was adapted objectively to assess the quality of life, in a qualitative fashion (Table 2). The Eastern Cooperative Oncology Group performance status scaleI4 was used to determine the level of activity of each patient. Each survey was performed by the same interviewer. Scores were assigned by the questioner for each of the items to express quantitatively the degree of physical and social well-being. The lower the score, the higher the discriminant power to indicate a good quality of life. Average scores were calculated for the response to each question and used as the index for the quality of life. Results are expressed as mean(s.d. ). Statistical analysis was performed using the Mann-Whitney rank sum test.
Results
Anu1jsi.c The 16-item survey examined food tolerance, body-weight, performance
Results with regard t o food tolerance, body-weight and performance s t a t u s are shown in Table3. The majority of patients were c o n s u m i n g a normal diet after o p e r a t i o n , b u t more t h a n 50 per cent of patients were unable t o tolerate t h e same volume of food. A b o u t half t h e patients had s o m e loss of appetite. Eleven of 33 patients had lost over 10 k g within 3 years of surgery b u t this incidence decreased t o t e n of 54 10 years after operation. Postoperative performance s t a t u s
248
0007-1 323/92/030248-03
______
C> 1992 Butterworth-Heinemann Ltd
Quality of life after gastrectorny: D. Korenaga et al.
Table 2 Questions and scoring for quality of life variables for patients who had undergone R , gastrectomy Question
Answers
Table 3 Results of interview Time after operation (years)
Scoring
.~
3-6
6-10 . ..
>. i._ n
( n = 32)
( n = 31)
( n = 54)
28 1 4
28
24 5 2
47 5 2
2
2 12 18
0
7 24
13 18
4 17 33
4 15 14
2 11 19
1 9 21
1 24 29
4
0 5
4 4
4 6
3 12 8
12 22
14 12 3 1 1
23 21 9 1 0
1-3 ( n = 33) ~~
1. How many times do you eat per day? 2. How long d o you take to eat?
3. What is the consistency of the food?
4. How large are the portions compared with before your illness?
5. What is your postoperative bodyweight?
6 How is your appetite?
7 Do you have problems swallowing?
8 Do you ever have diarrhoea?
9 D o you ever have heartburn?
10 D o you ever feel uncomfortable after
eating?
I1 D o you ever have abdominal pain?
12 D o you ever vomit?
13 D o you tire easily?
14. Do you ever have dizziness?
15. Have you ever seen a doctor because
of intestinal obstruction?
2-3 times 4-5 times >, 6 times 1 2 0 min 20-30 min > 30 min Normal Soft Liquid Increased Unchanged 2 / 3 pre-disease 1/2 pre-disease 1/3 pre-disease Increased Unchanged < 5 kg loss 5-10 kg IOSS > 10 kg loss Good Fair Poor Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often No Yes, but not surgically treated Yes., sureicallv u treated i
16. What is your level of activity (performance status)? PS 0: Fully active, able to carry on all pre-disease performance without restrictions. PS 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature: light housework, office work. PS 2: Ambulatory and capable of total self-care but unable to carry out any work activities; up and about more than 50 per cent of waking hours. PS 3: Capable of only limited self-care, confined to bed or chair more than 50 per cent of waking hours. PS 4: Completely disabled, incapable of any selfcare; totally confined to bed or chair.
Br. J. Surg.. Vol. 79, No. 3. March 1992
Consistency of food Normal Soft Liquid Volume of food* Increased Unchanged Decreased Appetite Good Fair
Poor Body-weight * Increased Unchanged Decreased 10 kg Performance status 0 1 2 3 4
1
3 1
7
7
10 11
11
8 16 7 2 0
10 17 4 0
9
1
10
*Compared with the weight before disease
Table 4 Scorr,for each question according to age Age at operation (years) Question no. 1
(1) (2) (3) (1)
(2) (3) (1)
(2) 13) \
I
(. 0, )
2 3 4 5 6 7 8 9 10 I1 12 13 14 15 16
< 59 ( n = 89)
> 60 ( n = 61)
P*
1.31(0.49) 1.48(0.62) 1.13(0.43 ) 2.88( 1.00) 3.73( 1.42 ) 2,48(0.58) 1.58(0.72) 1.46(0.54) 1.50(0.67) 1.56(0.70) 1.26(0.53) I .I 6(0.43 ) 1.51(0.67) 1.39(0.61) 1.30(0.59) 0.60(0.79)
1.36(0.57) 1.63(0.73 ) 1.32(065) 2.95( 1.03) 3.70( 1.29) 2.52(062 ) 1.59(0.69 ) 1.34(0.54) 1.37(061) 1.37(0*52) 1.21(0.45 ) 1.16(0.41 ) 1.39(0.58) 1.29(038 ) 1.19(0.47 ) 1.27(0.79 )
0.80 0.22
248-250
D. Korenaga, H. Orita, T. Okuyama, S. Moriguchi, Y. Maehara and K. Sugimachi Department of Surgery 11, Faculty of Medicine, Kyushu University, Fukuoka 812, Japan Correspondence to: Dr D. Korenaga
Quality of life after gastrectomy in patients w i t h carcinoma of the stomach One hundred and jifty patients without recurrence of disease after R, gastrectomy f o r carcinoma of the stomach were interviewed to determine their quality of life after surgery. Patients ate less and weighed less but most appeared to be well adjusted and had an optimistic attitude regarding their physical state. There was no evidence of a diminished quality of life in those who had undergone distal partial gastrectomy. These patients had a higher overall food tolerance, body-weight and performance status compared with those treated by total gastrectomy. Considering the satisfactory outcome and the sustained quality of life, radical R, gastrectomy may be the treatment of choice f o r carcinoma of the stomach.
Extensive l y m p h node dissection and c o m b i n e d resection of involved organs gives a significant prolongation of survival for Such patients with gastric cancer treated by curative en bloc o p e r a t i o n s h a v e a greater m a r g i n of safety, t h e operative - ~ . patients with mortality rate being less t h a n 5 per ~ e n t ~ Since carcinoma of the s t o m a c h a r e surviving for longer periods of time m o r e attention should be directed t o t h e relief of s y m p t o m s and t o t h e quality of life. T h e quality of life of patients w h o have undergone surgery for c a r c i n o m a of the o e s o p h a g ~ s *or~ ~ or repair of a b d o m i n a l a o r t i c a n e u r y s m ' h a s been discussed. Little is k n o w n of the results following radical surgery for gastric cancer. In this study, food tolerance, body-weight a n d performance s t a t u s were determined i n patients with no recurrence of disease after R, gastrectomy for carcinoma. T h e objective of t h e study was t o clarify whether t h e operative procedure was justified in terms of t h e quality of life in such patients after operation.
Patients and methods Pu/ienfs One hundred and fifty patients with carcinoma of the stomach who had undergone R, gastrectomy between 1969 and 1987 were studied. All were in good clinical condition without recurrence of disease when the survey was carried out in 1989. Clinical data are shown in Tahk 1 ; 83 patients had undergone distal partial gastrectomy and 67 total gast rect omy . Surqicul prowdures
R, gastrectomy had been performed as described by the Japanese Research Society for Gastric Cancer'. The entire greater omentum, superior leaf of the mesocolon, pancreatic capsule and lesser omentum had been removed en bloc with the stomach. When the tumour had involved the middle or lower third of the stomach, a distal partial gastrectomy had been performed with dissection of the perigastric nodes along lesser and greater curvatures and those in the right paracardial, suprapyloric and infrapyloric regions. Extragastric nodes, such as those along the left gastric, splenic, coeliac and common hepatic arteries, had also been dissected. The left gastric artery had been ligated and divided at its origin. When the tumour had been located in the upper third of the stomach total gastrectomy had been carried out. Lymphadenectomy in the left paracardial region had also been performed. In general, splenectomy had not proven necessary in patients with early gastric carcinoma. Reconstructive surgery had used an intestinal loop brought up to the lower oesophagus through an antecolic route. Oesophagojejunostomy had been performed in an end-to-side fashion. An enteroenterostomy had been constructed about 35-40 cm distant from the oesophagojejunostomy.
Table 1 Purim/ derails No. of patients Age (years) < 59 2 60 Sex ratio ( M : F ) Type of surgery Distal gastrectomy Billroth 1 Billroth I1 Total gastrectomy With splenectomy Without splenectomy Stage of disease* I I1 111 1v Time after operation (years) 1-3 3-6 6- 10
> 10 Total
89 61 97:53 43 40 34 33 67 27 46 10 33 32 31 54 150
*Japanese staging system
status and was adapted objectively to assess the quality of life, in a qualitative fashion (Table 2). The Eastern Cooperative Oncology Group performance status scaleI4 was used to determine the level of activity of each patient. Each survey was performed by the same interviewer. Scores were assigned by the questioner for each of the items to express quantitatively the degree of physical and social well-being. The lower the score, the higher the discriminant power to indicate a good quality of life. Average scores were calculated for the response to each question and used as the index for the quality of life. Results are expressed as mean(s.d. ). Statistical analysis was performed using the Mann-Whitney rank sum test.
Results
Anu1jsi.c The 16-item survey examined food tolerance, body-weight, performance
Results with regard t o food tolerance, body-weight and performance s t a t u s are shown in Table3. The majority of patients were c o n s u m i n g a normal diet after o p e r a t i o n , b u t more t h a n 50 per cent of patients were unable t o tolerate t h e same volume of food. A b o u t half t h e patients had s o m e loss of appetite. Eleven of 33 patients had lost over 10 k g within 3 years of surgery b u t this incidence decreased t o t e n of 54 10 years after operation. Postoperative performance s t a t u s
248
0007-1 323/92/030248-03
______
C> 1992 Butterworth-Heinemann Ltd
Quality of life after gastrectorny: D. Korenaga et al.
Table 2 Questions and scoring for quality of life variables for patients who had undergone R , gastrectomy Question
Answers
Table 3 Results of interview Time after operation (years)
Scoring
.~
3-6
6-10 . ..
>. i._ n
( n = 32)
( n = 31)
( n = 54)
28 1 4
28
24 5 2
47 5 2
2
2 12 18
0
7 24
13 18
4 17 33
4 15 14
2 11 19
1 9 21
1 24 29
4
0 5
4 4
4 6
3 12 8
12 22
14 12 3 1 1
23 21 9 1 0
1-3 ( n = 33) ~~
1. How many times do you eat per day? 2. How long d o you take to eat?
3. What is the consistency of the food?
4. How large are the portions compared with before your illness?
5. What is your postoperative bodyweight?
6 How is your appetite?
7 Do you have problems swallowing?
8 Do you ever have diarrhoea?
9 D o you ever have heartburn?
10 D o you ever feel uncomfortable after
eating?
I1 D o you ever have abdominal pain?
12 D o you ever vomit?
13 D o you tire easily?
14. Do you ever have dizziness?
15. Have you ever seen a doctor because
of intestinal obstruction?
2-3 times 4-5 times >, 6 times 1 2 0 min 20-30 min > 30 min Normal Soft Liquid Increased Unchanged 2 / 3 pre-disease 1/2 pre-disease 1/3 pre-disease Increased Unchanged < 5 kg loss 5-10 kg IOSS > 10 kg loss Good Fair Poor Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often Never Sometimes Often No Yes, but not surgically treated Yes., sureicallv u treated i
16. What is your level of activity (performance status)? PS 0: Fully active, able to carry on all pre-disease performance without restrictions. PS 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature: light housework, office work. PS 2: Ambulatory and capable of total self-care but unable to carry out any work activities; up and about more than 50 per cent of waking hours. PS 3: Capable of only limited self-care, confined to bed or chair more than 50 per cent of waking hours. PS 4: Completely disabled, incapable of any selfcare; totally confined to bed or chair.
Br. J. Surg.. Vol. 79, No. 3. March 1992
Consistency of food Normal Soft Liquid Volume of food* Increased Unchanged Decreased Appetite Good Fair
Poor Body-weight * Increased Unchanged Decreased 10 kg Performance status 0 1 2 3 4
1
3 1
7
7
10 11
11
8 16 7 2 0
10 17 4 0
9
1
10
*Compared with the weight before disease
Table 4 Scorr,for each question according to age Age at operation (years) Question no. 1
(1) (2) (3) (1)
(2) (3) (1)
(2) 13) \
I
(. 0, )
2 3 4 5 6 7 8 9 10 I1 12 13 14 15 16
< 59 ( n = 89)
> 60 ( n = 61)
P*
1.31(0.49) 1.48(0.62) 1.13(0.43 ) 2.88( 1.00) 3.73( 1.42 ) 2,48(0.58) 1.58(0.72) 1.46(0.54) 1.50(0.67) 1.56(0.70) 1.26(0.53) I .I 6(0.43 ) 1.51(0.67) 1.39(0.61) 1.30(0.59) 0.60(0.79)
1.36(0.57) 1.63(0.73 ) 1.32(065) 2.95( 1.03) 3.70( 1.29) 2.52(062 ) 1.59(0.69 ) 1.34(0.54) 1.37(061) 1.37(0*52) 1.21(0.45 ) 1.16(0.41 ) 1.39(0.58) 1.29(038 ) 1.19(0.47 ) 1.27(0.79 )
0.80 0.22
