| Part I:Prognostic Analysis of Patients After Total Gastrectomy for Gastric CancerPurpose:Gastric cancer is one of the most common malignant tumors in the world. Total gastrectomy is one common surgical treatment for gastric cancer, and is increasingly applicable because of the changes in the characteristics of the tumor anatomical site and the strategies of treatment. Analyze the clinical and pathological characters of patients after total gastrectomy for gastric cancer and explore the relevant factors influencing survival time to provide a theoretical reference for the clinical practice.Material and methods:Between August2006and August2010,383cases who had undergone total gastrectomy for gastric cancer in shanghai cancer center fudan university were enrolled and followed up for a retrospective analysis, including male288(75.2%) and female95(24.8%) with age ranged from26to82(mean age57.9). Of these,40cases (10.44%) underwent total remnant gastrectomy. It involved314cases (82%) underwent radical resection. On average,21.8lymph nodes were dissected and the positive rate of lymph node metastasis was37.6%. The rate of positive margin of specimen was8.1%and overall morbidity was8.4%and no surgery-related death. Upper abdominal midline incision was chosen for330cases (86.2%) and left thoracoabdominal incision for35cases (9.1%). Digestive tract reconstruction method was summarized as below:Roux-en-Y group of195(50.9%), Roux-en-Y with single jejunal pouch group of107(27.9%), esophageal jejunal loop with Braun anastomosis group of67(17.5%) and jejunal interposition with double pouch group of14(3.7%). The distribution of pathological tumor stage showed that36for stage1(9.40%),56for stage II (14.62%),261for stage Ⅲ (68.1%) and30for stage IV (7.8%). SPSS17.0software was used for statistical process. Kaplan-Meier survival curve was applied for survival analysis and Log-rank test for univariate analysis and Cox regression model for multivariate survival analysis.Results:The overall follow-up rate of these383cases was90.3%with a mean follow-up time of23.7mths and a median follow-up time of20.0mths. The survival rates of1-year,2-year and3-year were78.8%,54.4%and43.2%, with a median survival time of27mths. Univariate analysis suggested that the prognostic factors for patients after total gastrectomy included:radical resection or not (P<0.001), the remnant gastrectomy or not (P=0.026), depth of tumor invasion (P＜0.001), lymph node stage (P＜0.001), TNM stage (P＜0.001), intravascular tumor thrombus (P<0.001) and nerve invasion (P<0.001). Tumor location, incision selection, method of reconstruction and combined organ resection were not associated with patients’survival. Multivariate analysis showed that the operation character, differentiation of tumor cell, depth of invasion stage and positive rate of lymph node metastasis were independent prognostic factors (P<0.05).Conclusion:Total gastrectomy was safe for gastric cancer with an acceptable surgery-related morbidity. Upper abdominal midline incision was appropriate for most cases and left thoracoabdominal incision could be chosen for lesions involving the lower esophagus. Patients underwent total gastrectomy for gastric cancer shows a poor prognosis with most staging III or IV. Total remnant gastrectomy shows a better survival than total gastrectomy, so second operation should be taken for patients with local recurrence after partial gastrectomy. Operation should achieve the goal of radical resection and extend lymphadenectomy. Although no benefit, combined organ resection should be taken for the purpose of radical resection if appropriate. Part II:Nutritional Consequences and Quality of Life After Total Gastrectomy by Roux-en-Y or Roux-en-Y with an Aboral Pouch Reconstruction for Gastric CancerPurpose:Total gastrectomy (TG) often brings patients weight loss, malabsorption malnutrition and so called "no stomach syndrome", resulting in deterioration of quality of life (QOL). Data on nutritional status and quality of life are scarce comparing Roux-en-Y (RY) and Roux-en-Y with an aboral pouch (RYP) reconstruction after TG for gastric cancer. We conducted this retrospective study to investigate the correlation between these two different digestive tract reconstructive methods and postoperative nutritional status and QOL of patients underwent TG for gastric cancer.Material and methods:Between August2006and August2010,302cases who had undergone total gastrectomy for gastric cancer in our center were selected and followed up for a retrospective analysis, including RY group195and RYP group107cases. RY group63and RYP group45cases who had received radical operation and had no recurrence in November2011for the last follow-up were enrolled in this study. Collect information as followed:(1) clinical and pathological data during hospitalization;(2) serumal albumin concentration, hemoglobin concentration and lymphocyte count and calculate the prognostic nutritional index (PNI);(3) information about adjuvant therapy;(4) questionary surveys which consist of body weight, dietary intake and postprandial disturbances in the last follow-up.Results:No significant differences were found between these two groups in terms of age, gender distribution, tumor stage, numbers of dissected lymph node and adjuvant therapy. The interval time from operation to study ranged from15.3mths to62.5mths with time in average of RY group35.5and RYP group27.9mths respectively (P=0.001). The mean body weight loss was7.4Kg from operation to study. More than15mths after operation, most patients had a stabilized body weight. On average,4.2meals per day brought nearly equal amount of daily consumption compared with preoperation. The morbidity of postprandial symptoms of heartburn, regurgitation and steatorrhea ranged from11%to19%. The hemoglobin level decreased slightly6mths after operation but recovered one year later. During the course of follow-up, the mean PNI value gradually increased. Male patients had a better body weight recovery than female cases (P=0.006). There were no significant differences between these two groups in terms of nutritional status and QOL.Conclusion:The simple use of a10cm long aboral pouch after TG was of no benefit to the patient with gastric cancer in respects of QOL and nutritional status compared with RY reconstruction. The difference of interval time between the two groups may be an important influencing factor for the result. |
PDF Full Text Request