Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update.

It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.

Clinical Relevance of Proximal Gastrectomy With Double-flap Esophagogastrostomy Reconstruction With Glycemic Profile and Postgastrectomy Syndromes.

BACKGROUND/AIM: The glycemic profile of patients who have undergone proximal gastrectomy (PG) using a continuous glucose monitoring (CGM) device has not been investigated. We aimed to investigate the association between postgastrectomy syndrome and the glycemic profile of patients who underwent PG and its impact on postoperative body weight loss and nutritional status. PATIENTS AND METHODS: We retrospectively investigated 65 patients with CGM post-surgery. Postoperative glycemic profiles were recorded using a CGM device. To evaluate postgastrectomy syndromes and quality of life (QOL), the Postgastrectomy Syndrome Assessment Scale 37-item questionnaire was employed. The dynamics of albumin and hemoglobin levels were investigated at 1 and 6 months postoperatively. RESULTS: The time below the range (percentage of glucose reading <70 mg/dl) in patients who underwent PG with double-flap (DF) esophagogastrostomy reconstruction was significantly shorter than in those who underwent total gastrectomy (TG). Late dumping scores tended to be better in patients after PG with DF than in those after TG. The body weight loss rate of patients who underwent PG with DF was similar to those who underwent TG. The albumin level at 6 months recovered to the preoperative level in patients who underwent PG with DF, but not in those who underwent TG. Hemoglobin levels at 1 and 6 months postoperatively were significantly higher in patients who underwent PG with DF than in those who underwent TG. CONCLUSION: Proximal gastrectomy with double-flap esophagogastrostomy reconstruction did not improve QOL or body weight loss, as expected, however, suppressed hypoglycemia, late dumping syndrome, and deterioration in nutritional status.

Effects of Proximal Gastrectomy and Various Clinical Factors on Postoperative Quality of Life for Upper-third Gastric Cancer Assessed using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45): A PGSAS NEXT Study.

BACKGROUND: It is important to determine the effect of clinical factors on several domains (symptoms, living status, and quality of life [QOL]) after gastrectomy to establish individualized therapeutic strategies. This study was designed to determine the factors-particularly surgical method-that influence certain domains after gastrectomy for proximal gastric cancer by using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire. METHODS: We conducted a nationwide study of PGSAS-45 questionnaire responses retrieved from 1950 (82.5%) patients from 70 institutions who had undergone gastrectomy for gastric cancer. Of these, 1,538 responses for proximal gastric cancer (1020 total gastrectomies and 518 proximal gastrectomies [PGs]) were examined. RESULTS: PG significantly and favorably affected four main outcome measures (MOMs): elderly affected 10 MOMs, male sex affected 4 MOMs, longer postoperative period affected 8 MOMs, preservation of the vagus nerve affected 1 MOM, adjuvant chemotherapy affected 1 MOM, clinical stage affected 2 MOMs, and more extensive lymph node dissection affected 2 MOMs. However, the laparoscopic approach had an adverse effect on MOMs and combined resection of other organs had no favorable effect on any MOMs. CONCLUSIONS: This PGSAS NEXT study showed that it is better to perform PG for proximal gastric cancer, even for patients with advanced cancer, to obtain favorable postoperative QOL if oncological safety is guaranteed. Because the MOMs of PGSAS-45 are positively and negatively influenced by various background factors, it also is necessary to provide personalized care for each patient to prevent deterioration and further improve symptoms, living status, and QOL postoperatively.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy.

PURPOSE: Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer. MATERIALS AND METHODS: Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity. RESULTS: The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8. CONCLUSION: The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Evaluation of postoperative quality of life by PGSAS-45 following local gastrectomy based on the sentinel lymph node concept in early gastric cancer.

BACKGROUND: The usefulness of sentinel node navigation surgery (SNNS) for early gastric cancer has been demonstrated in a multicenter prospective study. However, quality of life (QOL) after local resection remains unclear. This present study investigated QOL after local resection and distal gastrectomy. METHODS: We examined 69 patients who underwent laparoscopic distal gastrectomy (LADG) (n = 44) and laparoscopic local resection (LLR) (n = 25) in our hospital between September 2011 and May 2018. We conducted a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET) with SNNS as LLR. All patients had pStage I or II and none had received adjuvant chemotherapy. We evaluated QOL using the postgastrectomy syndrome assessment scale questionnaire (PGSAS-45) 1, 6, and 12 months after surgery. RESULTS: In PGSAS-45, no significant differences were observed between LLR and LADG at 1 and 6 months after surgery. At 12 months, the LLR group scored better for some of the subscales (SS). In the endoscopic evaluation, the LLR group showed significant improvements in residual gastritis at 6 months (P = 0.006) and esophageal reflux and residual gastritis at 12 months (P = 0.021 and P = 0.017). A significant difference was observed in the prognostic nutritional index, which was assessed using serum samples, between the two groups at 6 months (P = 0.028). The body weight ratio was better in the LLR group than in the LADG group at 6 and 12 months (P = 0.041 and P = 0.007, respectively). CONCLUSIONS: CLEAN-NET with SNNS preserved a better QOL and nutrition status than LADG in patients with early gastric cancer.

Fecal incontinence after total mesorectal excision for rectal cancer-impact of potential risk factors and pelvic intraoperative neuromonitoring.

BACKGROUND: Fecal incontinence frequently occurs after total mesorectal excision for rectal cancer. This prospective study analyzed predictive factors and the impact of pelvic intraoperative neuromonitoring at different follow-up intervals. METHODS: Fifty-two patients were included undergoing total mesorectal excision for rectal cancer, and 29 under control of pelvic intraoperative neuromonitoring. Fecal incontinence was assessed using the Wexner Score at 3 and 6 months after stoma closure (follow-ups 1 and 2) as well as 1 and 2 years after surgery (follow-ups 3 and 4). Risk factors were identified by means of logistic regression. RESULTS: New onset of fecal incontinence was significantly lower in the neuromonitoring group at each follow-up (follow-up 1: 2 of 29 patients (7%) vs. 8 of 23 (35%), (p = 0.014); follow-up 2: 3 of 29 (10%) vs. 9 of 23 (39%), (p = 0.017); follow-up 3: 5 of 29 (17%) vs. 11 of 23 (48%), p = 0.019; follow-up 4: 6 of 28 (21%) vs. 11 of 22 (50%), p = 0.035). Non-performance of neuromonitoring was found to be an independent predictor for fecal incontinence throughout the survey. Neoadjuvant chemoradiotherapy was an independent predictor in the further course 1 and 2 years after surgery. CONCLUSIONS: Performance of pelvic intraoperative neuromonitoring is associated with significantly lower rates of fecal incontinence. Neoadjuvant chemoradiotherapy was found to have negative late effects. This became evident 1 year after surgery.

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

BACKGROUND: Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. METHODS: Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6 days (range 1-30 days), and median duration of hospitalization was 13 days (range 3-135 days). At the follow-up (mean 24.6 months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. CONCLUSIONS: Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) can result in de novo and worsen preexisting gastroesophageal reflux disease (GERD). Post-LSG patients with GERD refractory to proton pump inhibitors (PPI) usually undergo more invasive, anatomy-altering Roux-en-Y gastric bypass surgery. Lower esophageal sphincter (LES) electrical stimulation (ES) preserves the anatomy and has been shown to improve outcomes in GERD patients. OBJECTIVE: To evaluate the safety and efficacy of LES-ES in post-LSG patients with GERD not controlled with maximal PPI therapy. SETTING: Prospective, international, multicenter registry. METHODS: Patients with LSG-associated GERD partially responsive to PPI underwent LES-ES. GERD outcomes pre- and poststimulation were evaluated based on quality of life, esophageal acid exposure (after 6-12 mo), and PPI use. RESULTS: Seventeen patients (11 female, 65%), treated at 6 centers between May 2014 and October, 2016 with a median follow-up of 12 months (range 6-24), received LES-ES. Median age was 48.6 years (interquartile range, 40.5-56), median body mass index 31.7 kg/m2 (27.9-39.3). All patients were on at least daily PPI preoperatively; at last follow-up, 7 (41%) were completely off PPI, 5 (29%) took PPI on an intermittent basis, and 5 (29%) were on single-dose PPI. Median GERD-health-related quality of life scores improved from 34 (on-PPI, 25-41) at baseline to 9 (6-13) at last follow-up (off-PPI, P<.001). Percentage of time with esophageal pH<4 improved from 13.2% (3.7-30.7) to 5.8% (1.1-54.4), P = .01. CONCLUSION: LES-ES in post-LSG patients suffering from symptomatic, PPI-refractory GERD resulted in significant improvement of GERD-symptoms, esophageal acid exposure, and need for PPI. Preserving the post-LSG anatomy, it offers a valid option for patients unable or unwilling to undergo Roux-en-Y gastric bypass surgery.

Quality of life after total vs distal gastrectomy with Roux-en-Y reconstruction: Use of the Postgastrectomy Syndrome Assessment Scale-45.

AIM: To investigate the detrimental impact of loss of reservoir capacity by comparing total gastrectomy (TGRY) and distal gastrectomy with the same Roux-en-Y (DGRY) reconstruction. The study was conducted using an integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45, recently developed by the Japan Postgastrectomy Syndrome Working Party. METHODS: The PGSAS-45 comprises 8 items from the Short Form-8, 15 from the Gastrointestinal Symptom Rating Scale, and 22 newly selected items. Uni- and multivariate analysis was performed on 868 questionnaires completed by patients who underwent either TGRY (n = 393) or DGRY (n = 475) for stage I gastric cancer (52 institutions). Multivariate analysis weighed of six explanatory variables, including the type of gastrectomy (TGRY/DGRY), interval after surgery, age, gender, surgical approach (laparoscopic/open), and whether the celiac branch of the vagus nerve was preserved/divided on the quality of life (QOL). RESULTS: The patients who underwent TGRY experienced the poorer QOL compared to DGRY in the 15 of 19 main outcome measures of PGSAS-45. Moreover, multiple regression analysis indicated that the type of gastrectomy, TGRY, most strongly and broadly impaired the postoperative QOL among six explanatory variables. CONCLUSION: The results of the present study suggested that TGRY had a certain detrimental impact on the postoperative QOL, and the loss of reservoir capacity could be a major cause.

Role of the gastroenterologist in the management of the obese patient. / Papel del digestólogo en el manejo del paciente obeso.

Obesity is a highly prevalent disease worldwide, and one in which gastroenterologists can play an important role. Some digestive diseases are more common in obese patients, and preoperative evaluation may be required in some cases. Additionally, bariatric surgery can lead to digestive complications in the short and long term that require intervention, and endoscopic treatment can be an important factor in weight loss. The aim of this review is to highlight the role of the gastroenterologist in the management of obese patients who are either scheduled for or have undergone surgical or endoscopic treatment for obesity.

Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared With laparoscopy-assisted distal gastrectomy: A cross-sectional postal questionnaire survey.

BACKGROUND: Little is known about postgastrectomy syndrome and quality of life (QOL after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). The aim of this study was to assess postgastrectomy syndrome and QOL after LAPPG as compared with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGBI). METHODS: Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaires were sent by mail to 167 patients. To balance the characteristics of the groups, propensity score matching was performed. RESULTS: Of the 167 patients sent questionnaires, 112 (67%) responded, including 47 who underwent LAPPG and 65 who underwent LADGBI. After propensity score matching, the LAPPG group scored significantly better on the diarrhea and dumping subscales. Multiple regression analysis showed that female sex and LADGBI were independent factors predicting dumping. Evaluation of outcome measures for singular symptom showed that the LAPPG group scored significantly worse on the acid regurgitation subscale, but significantly better on the lower abdominal pain and early dumping abdominal subscales. CONCLUSION: LAPPG is superior to LADGBI for ameliorating postgastrectomy syndrome and maintaining QOL. LAPPG is recommended for patients with cT1N0 middle third gastric cancer.

Impaired Gastrointestinal Function Affects Symptoms and Alimentary Status in Patients After Gastrectomy.

BACKGROUND: Postgastrectomy syndrome (PGS) remains a common complication after gastrectomy that affects patients' quality of life. Although impaired gastrointestinal (GI) function by gastrectomy procedures is thought to be the cause, the precise pathophysiology of PGS is yet to be clarified. AIM: The aim of this study was to investigate relationships between GI function and various symptoms or alimentary status in patients after gastrectomy. METHODS: Fifty-one patients who underwent total or distal gastrectomy at least 1 year previously were studied. All patients replied to a questionnaire that asked presence of symptoms (esophageal reflux, nausea, abdominal pain, early satiation, diarrhea, early dumping general, early dumping abdominal, and late dumping symptoms) and alimentary status (change in body weight, food intake per meal, frequency of meals per day). They also underwent assessment of GI function consisting of gastric emptying study by 13C-acetate breath test to examine reservoir capacity and gastric emptying, and water load drink test to evaluate tolerance to volume loading (TVL). The relationships between GI function and each symptom or alimentary status were examined. RESULTS: The patients with nausea and early dumping general symptoms had significantly smaller reservoir capacity*, the patients with diarrhea and early dumping general symptoms had significantly faster gastric emptying*, and the patients with early satiation and early dumping abdominal symptoms had significantly impaired TVL*. Significant correlations were identified between TVL and body weight changes* or food intake per meal* (* p < 0.05). CONCLUSION: Impaired postoperative GI function was closely related to symptoms or worse alimentary status.

Retrograde jejunal intussusception after total gastrectomy: A case report and literature review.

Retrograde jejunal intussusception is a rare disease. A 60-year-old female patient was hospitalized due to vomiting for 2 days, with a history of radical gastrectomy plus esophagus jejunum Rouxs-en-Y. On examination, there was a palpable wax-like mass on the left-hand side underneath the umbilicus. Computerized tomography scan showed a proximal jejunal intussusception. During surgery, the distal jejunum was found set into the proximal jejunum for a length of 30 cm, and bowel necrosis was also observed. The necrotic tube was resected and anastomosis was performed. Four days after the surgery, gastrointestinal function resumed. After a 10-month follow-up, the patient had no discomfort.

Assessment of postoperative quality of life following pylorus-preserving gastrectomy and Billroth-I distal gastrectomy in gastric cancer patients: results of the nationwide postgastrectomy syndrome assessment study.

BACKGROUND: Pylorus-preserving gastrectomy (PPG) is increasingly being used to treat early gastric cancer in the middle third of the stomach, with the hope of ameliorating postoperative dysfunction and improving quality of life (QOL). We evaluated symptoms of postgastrectomy syndrome (PGS) and QOL by means of a newly developed integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), and compared PPG with Billroth-I distal gastrectomy (DGBI). METHODS: The PGSAS-45 consists of 45 items, including items from the SF-8 and GSRS instruments, as well as 22 newly selected items. It was designed to assess the severity of PGS and the living status and QOL of gastrectomized patients. The nationwide PGSAS surveillance study enrolled 2,368 gastric cancer patients who underwent various types of gastrectomy. In this study we analyzed 313 PPG patients and 909 DGBI patients. RESULTS: Body weight loss was -6.9% in the PPG group and -7.9% in the DGBI group (P = 0.052). The PPG group scored better on the diarrhea subscale (PPG; 1.8 vs. DGBI; 2.1, P < 0.0001), dumping subscale (1.8 vs. 2.0, P = 0.003), and frequency of additional meals (1.8 vs. 1.9, P = 0.034). Multiple regression analysis revealed that age and the preservation of the celiac branch of the vagus nerve were independent factors predicting diarrhea and dumping. CONCLUSIONS: It has been suggested that PPG is superior to DGBI for ameliorating PGS. Preservation of the celiac branch of the vagus nerve is recommended to reduce postoperative disorders regardless of the reconstruction method used.

Long-term comparison of boomerang-shaped jejunal interposition and Billroth-I reconstruction after distal gastrectomy.

BACKGROUND: Billroth-I (BI) is a simple, physiological method of reconstruction following distal gastrectomy. In actuality, postoperative QOL is by no means favorable due to the high incidence of post-gastrectomy syndrome. The aim of this study is to assess the safety and efficacy of boomerang-shaped jejunal interposition (BJI) after distal gastrectomy. METHODS: Sixty-six patients with early gastric cancer underwent the BI procedure (n = 33) or BJI (n = 33) after distal gastrectomy, following which they were compared for 5 years. Tumor characteristics, operative details, postoperative complications and complaints, number of meals, and body weight were analyzed. Patients were followed up by endoscopy every 12 months. RESULTS: There were no significant differences in the incidence of postoperative complications. The incidence of heartburn (30 vs. 0 %, P = 0.0009) and oral bitterness (33 vs. 6 %, P = 0.0112) were significantly lower in the BJI cases. Endoscopic findings revealed significantly lower incidences of reflux esophagitis (24 vs. 0 %, P = 0.0051) and remnant gastritis (70 vs. 3 %, P < 0.0001) in the BJI group. The incidence of food stasis was low in both groups (12 vs. 15 %). In the BJI group, 30 patients (90 %) were eating 3 meals/day within 12 months, whereas in the BI group, 16 patients (48 %) were still eating 5 meals/day at 12 months or later. CONCLUSIONS: BJI is as safe as BI, but is better in terms of improvement in bile reflux and food intake without stasis. This procedure, therefore, appears to be a useful method for reconstruction after distal gastrectomy.

[RESULTS OF GASTROPLASTY, USING ILEOCECAL SEGMENT OF INTESTINE AFTER COMBINED GASTRECTOMY].

Results of treatment of 18 patients for locally spread gastric cancer, in whom after combined gastrectomy gastroplasty was accomplished, using ileocecal intestinal segment (the main group), were presented. In a comparison group 20 patients were included, in whom after combined gastrectomy end-to-loop esophagojejunoanastomosis was formated. Early postoperative complications have occurred in the main group--in 7 (38.8%) patients, and in comparison group--in 6 (30%). Postoperatively 2 (11.1%) and 2 (10%) patients died, accordingly. Gastroplasty, using ileo-cecal intestinal segment, have promoted reduction of the remote postgastrectomy syndromes occurrence rate from 58.8 to 11.1%. In a comparison group median survival was 18.6 mo, and in the main--a survival mediana was not achieved, because the investigation still goes on.

Evaluation of postgastrectomy symptoms after distal gastrectomy with Billroth-I reconstruction using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

BACKGROUND: Distal gastrectomy with Billroth-I reconstruction (DGBI) is the most commonly used treatment approach for gastric cancer patients in Japan. The aim of this study was to assess and elucidate the effect of different surgical DGBI techniques on postgastrectomy syndrome (PGS) using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45). METHODS: The newly created PGSAS-45 composed of 45 questions was used in this study. The scale was distributed to 2,922 patients who underwent gastrectomy >1 year prior. Completed forms were returned by 2,520 patients (86 %), of which 909 underwent DGBI. The effects of performing the Kocher maneuver, differences in the size of the gastric remnant and differences the anastomosis technique had on the main outcome measures of PGSAS-45 were analyzed. RESULTS: Patients for whom the Kocher maneuver was performed experienced significantly worse meal-related distress and poorer quality of ingestion. Additionally, a less satisfactory physical and mental component summary from the SF-8 was reported. Patients with larger gastric remnants showed significantly better scores on the diarrhea subscale, a slightly better trend for the need for additional meals and dissatisfaction with eating. Regarding the anastomosis technique, there was no difference between the hand-sewn, circular stapler (CS) and linear stapler end-to-end anastomosis, and there was also no difference between the end-to-end and side-to-end anastomosis with the CS. CONCLUSIONS: The Kocher maneuver may increase meal-related distress, reduce the quality of ingestion and impart a negative effect on quality of life (QOL). The larger gastric remnants may cause reduction in diarrhea and an improvement in meal-related scores.

Bsm1 vitamin D receptor polymorphism and calcium homeostasis following bariatric surgery.

PURPOSE/AIM: To evaluate the association between the Bsm1 vitamin D receptor polymorphism and the calcium-vitamin D-parathormone axis following bariatric surgery. MATERIALS AND METHODS: This cross-sectional study included 86 morbidly obese patients, who underwent either gastric bypass or sleeve gastrectomy, with a mean follow-up of four years. Calcium metabolism indices and bone turnover markers were assessed according to the presence of secondary hyperparathyroidism and the Bsm1 vitamin D receptor genotypes. RESULTS: Secondary hyperparathyroidism (42.2% of sample) was associated with lower levels of 25hydroxyvitamin D and elevated markers of bone turnover. In subjects without secondary hyperparathyroidism, presence of the unfavorable B allele resulted in higher levels of parathormone (Bb and BB vs. bb genotype: 50.3 ± 8.2 pg/dl vs. 44.4 ± 10.7 pg/dl, p = .011, adjusted for weight loss, baseline body mass index, 25hydroxyvitamin D, surgical procedure, and duration after surgery). In the whole sample, patients bearing the unfavorable B allele exhibited lower weight loss, a parameter that was negatively associated with markers of bone resorption. CONCLUSIONS: Secondary hyperparathyroidism is highly prevalent after bariatric surgery. Bsm1 vitamin D receptor polymorphism may have an effect in early stages of calcium metabolism imbalance, while no association is detected in patients who have already developed secondary hyperparathyroidism. Moreover, vitamin D receptor polymorphism is associated with post-surgery weight loss, a process related to bone turnover.

Characteristics and clinical relevance of postgastrectomy syndrome assessment scale (PGSAS)-45: newly developed integrated questionnaires for assessment of living status and quality of life in postgastrectomy patients.

BACKGROUND: Lack of a suitable instrument to comprehensively assess symptoms, living status, and quality of life in postgastrectomy patients prompted the authors to develop postgastrectomy syndrome assessment scale (PGSAS)-45. METHODS: PGSAS-45 consists of 45 items in total: 8 items from SF-8, 15 items from GSRS, and an additional 22 items selected by 47 gastric surgeons. Using the PGSAS-45, a multi-institutional survey was conducted to determine the prevalence of postgastrectomy syndrome and its impact on everyday life among patients who underwent various types of gastrectomy. Eligible data were obtained from 2,368 patients operated and followed at 52 institutions in Japan. Of these, data from 1,777 patients were used in the current study in which symptom subscales of the PGSAS-45 were determined. We also considered the characteristics of the postgastrectomy syndrome and to what extent these symptoms influence patients' living status and quality of life (QOL). RESULTS: By factor analysis, 23 symptom-related items of PGSAS-45 were successfully clustered into seven symptom subscales that represent esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation, and dumping. These seven symptom subscales and two other subscales measuring quality of ingestion and dissatisfaction for daily life, respectively, had good internal consistency in terms of Cronbach's α (0.65-0.88). CONCLUSION: PGSAS-45 provides a valid and reliable integrated index for evaluation of symptoms, living status, and QOL in gastrectomized patients.

Evaluation of QOL after proximal gastrectomy using a newly developed assessment scale (PGSAS-45).

BACKGROUND: Proximal gastrectomy with esophagogastrostomy (PGEG) has been widely applied as a comparatively simple method. In this study, we used a questionnaire survey to evaluate the influence of various surgical factors on post-operative quality of life (QOL) after PGEG. METHODS: In this post-gastrectomy syndrome assessment study, we analyzed QOL in 2,368 cases. Among these, 193 had undergone proximal gastrectomy and 115 had undergone PGEG. The Post-Gastrectomy Syndrome Assessment Scale (PGSAS)-45 is a questionnaire consisting of 45 items, including the SF-8, the Gastrointestinal Symptom Rating Scale (GSRS), and other symptom items seemed to be specific to post-gastrectomy. The 23 symptom items were composed of seven symptom subscales (SS), including esophageal reflux, abdominal pain, and meal-related distress. These seven SS, total symptom score, ingested amount of food per meal, necessity for additional meals, quality of ingestion SS, ability to work, dissatisfaction with symptoms, dissatisfaction with the meal, dissatisfaction with working, dissatisfaction with daily life SS and change in body weight were evaluated as main outcome measures. In PGEG cases, we evaluated the influence on QOL of various surgical factors, such as procedures to prevent gastroesophageal regurgitation and size of the remnant stomach. RESULTS: The scores for esophageal reflux and dissatisfaction with the meal were higher in patients who had not undergone an anti-reflux procedure. In most cases, the preserved remnant stomach was more than two-thirds the size of the pre-operative stomach. When comparing patients with a remnant stomach two-thirds the pre-operative size and those with more than three-quarters, the diarrhea SS and necessity for additional meals scores were lower in the group with more than three-quarters. The indigestion, constipation, and abdominal pain subscales, and the total symptom score, were higher in patients who had not undergone pyloric bougie than in those who had. CONCLUSION: These results indicated that QOL was better in patients with a large remnant stomach. Procedures to prevent gastroesophageal reflux, and the use of pyloric bougie as a complementary drainage procedure, were considered effective ways to reduce the deterioration of QOL.