Health Economics And Quality of Life Between Uncut Roux-En-Y And Roux-En- Y Reconstruction After Total Gastrectomy


 Purpose: This study aims to compare the health economics and quality of life between uncut Roux-en-Y and Roux-en-Y reconstruction after laparoscopic-assisted total gastrectomy.Methods: Between January 2016 and January 2019, 164 patients underwent laparoscopic-assisted total gastrectomy (uncut Roux-en-Y reconstruction, n = 71; Roux-en-Y, n = 93). The patients’ data were collected and reviewed retrospectively.Results: The perioperative index, operating time, digestive tract reconstruction time, and first postoperative exhaust time of the U-RY group were shorter than those of the RY group (P < 0.05). Differences in the quality of life (QoL) index 12 months postoperation were not significantly different between the groups (P > 0.05). No recanalization was found in the U-RY obliterated afferent jejunal limb. The cost of mechanical staples andaverage hospitalization in the U-RY group were significantly lower than that in the RY group (P < 0.05).Conclusion: The postoperative health economics of U-RY reconstruction may be superior to those of RY reconstruction after laparoscopic-assisted total gastrectomy. The QoL of the U-RY group is similar to that of the RY group.


Observation indicators and evaluation standards
The operation time, digestive tract reconstruction time, intraoperative blood loss, rst exhaust time, postoperative hospital stay, and perioperative complications were monitored during the perioperative period.
Average hospitalization and mechanical staple costs were also recorded as health economics.
The QoL index of the two groups 1 year after operation was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-STO22 questionnaires. 12 Gastroscopy and upper gastrointestinal angiography were reviewed 1 year after surgery, and recanalization of the jejunal occlusion in the U-RY group, if any, was recorded.
The EORTC QLQ-C30 (V3.0) questionnaire is 30-item scale for cancer patients. Except for items 29 and 30, the scores for which ranged from 1 to 7, all other items were scored from 1 to 4, corresponding to the response categories "never," " a little," "quite a bit," and "very much." The 30 items could be divided into 15 elds, including ve functional elds (i.e., physical, role, cognitive, emotional, and social), three symptom elds (i.e., pain, fatigue, nausea and vomiting), one global health status eld, and six single items(each as a eld, i.e., Appetite loss, Insomnia, Constipation, Dyspnea, Diarrhea, Financial di culties). 13 The EORTC QLQ-STO22 questionnaire consists of 22 items that can be divided into 9 areas: ve symptom areas (i.e., dysphagia, pain, eating restrictions, re ux symptoms, and anxiety) and four single items (i.e., dry mouth, taste, body image, and hair loss). 14 The QLQ-C30 and QLQ-STO22 responses were linearly transformed into scores ranging from 0 to 100 according to the EORTC scoring manual. High scores for items related to global health status and functions and low scores for items related to symptoms and ten single items (i.e., Appetite loss, Insomnia, Constipation, Dyspnea, Diarrhea, Financial di culties, dry mouth, taste, body image, and hair loss) denote a favorable QoL. The baseline QoL was obtained prior to the operations. Postoperative QoL scores were collected 1, 6, and 12 months after the operation by telephone calls, letters, or outpatient visits. The follow-up period was up to January 2020.
Statistical analysis SPSS version 25.0 software (SPSS, Chicago, IL, USA) was used for statistical analysis. Continuous variables were compared using independent-samples t test and are expressed as mean ± standard deviation. The frequencies of categorical variables are expressed as rates, and rates were compared using the chisquared or Fisher's exact test. Here, P < 0.05 was considered statistically signi cant.

Patient characteristics
A total of 176 patients were included in this work on the basis of the inclusion and exclusion criteria described above. Seven patients were lost to follow-up and ve died (i.e., two patients in the U-RY group and three patients in the RY group). Finally, 164 patients (male = 135, 82.3%; female = 29, 17.7%) were included in this study. These patients were divided into the U-RY (n = 71) and RY (n = 93) groups according to the technique used for digestive tract reconstruction. The baseline characteristics of the two groups were comparable (Table 1). Perioperative condition and health economics No deaths were recorded during the perioperative period. The operation, digestive tract reconstruction, and rst postoperative exhaust times of the U-RY group were shorter than those of the RY group (P < 0.05). The rates of incidence of speci c complications in the two groups were 12.7% and 16.1%, respectively, but the difference observed was not statistically signi cant. All perioperative complications were cured by conservative treatment, and no case of secondary operation was noted. The cost of mechanical staples and average hospitalization in the U-RY group were signi cantly lower than that in the RY group (P < 0.05; Table 2). Twelve months postoperation, the main symptoms of the patients included postprandial abdominal pain and discomfort, sulks, and re ux. No signi cant difference in QoL was noted between the two groups at baseline and various time points after surgery (P > 0.05).
QLQ-C30 scale: The scores of physical functioning, role functioning (Whether limited in doing work, other daily activities, pursuing hobbies and other leisure time activities), social functioning, and global health status increased whereas the scores of pain and fatigue decreased in both groups. The pain scores of the two groups were relatively high from 1 month to 12 months postoperation.
QLQ-STO22 scale: From 1 month to 12 months after surgery, symptoms such as dysphagia, re ux, Pain and restricted eating signi cantly improved. At 6 months postoperation, the hair loss and taste scores of the two groups remained relatively high. The scores of re ux symptoms 12 months after RY anastomosis were lower than those observed after U-RY, but the difference between groups was not signi cant (P > 0.05). No signi cant improved in other symptoms, such as dry mouth, changes in taste, anxiety, body image, and hair loss, were found ( Fig. 4, Table 3).

Discussion
Some controversy exists regarding the application of U-RY anastomosis to digestive tract reconstruction after laparoscopic-assisted total gastrectomy. In particular, two main aspects are debated: (1) In terms of surgical safety and feasibility, the length of the mesentery may be too short, which could result in excessive tension of the esophagojejunostomy and increased incidence of anastomotic leakage during U-RY reconstruction. Moreover, when the tumor is located at the gastroesophageal junction, the anastomotic site of the esophagojejunostomy tends to be at a higher position ("at a high position" relative to esophagogastric junction). Thus, the afferent and efferent jejunal limbs may be embedded in the esophageal hiatus, and mechanical intestinal obstruction may develop. (2) The possibility of dehiscence and recanalization of the jejunal occlusion cannot be excluded, and severe re ux esophagitis may occur after recanalization. [15][16][17] Prevention of closure point recanalization after uncut Roux-en-Y anastomosis for radical resection of gastric cancer Uncut Roux-en-Y anastomosis is widely used in gastrointestinal reconstruction procedure after radical gastrectomy for gastric cancer. However, the proximal jejunal closure point recanalization of the input loop is an important complication of postoperative patients with prolonged time, resulting in pancreatic juice or bile re ux, which can lead to in ammatory lesions of the remnant stomach or esophagus. Poor selection of the location of the closure point during anastomosis causes a large amount of food deposited in the blind loop to be pushed and impacted, resulting in loosened threads or failed U-shaped staples, which may cause recanalization complications. Most scholars believe that the shortening of the jejunal tube closure point to the optimal position of 2 to 3 cm from the residual gastrojejunostomy can signi cantly reduce food retention, decrease the pressure of the closure point and the incidence of recanalization. 18 At present, the application of new anastomotic techniques and materials such as four row and six-row U-shaped staples and 7# wire ligation under laparoscopy can prevent the occurrence of recanalization of the closure point. Uncut Roux-en-Y anastomosis is safe and has few complications, and is expected to become one of the best ways of digestive tract reconstruction. 18 In terms of perioperative conditions This study found that the incidence of short-term complications in the U-RY group is similar to that in the traditional RY group (P > 0.05). During digestive tract reconstruction in the U-RY group, a small number of patients with obesity and too high severed esophagus (approximately 5 cm) exhibited mesenteric tension ("too high severed esophagus" relative to esophagogastric junction). We performed mesentery incision and release and cut open part of the diaphragm to enlarge the space of the diaphragm hiatus and solve problems related to the safety and feasibility of the operation. The operation, digestive tract reconstruction, and rst postoperative exhaust times of the U-RY group were shorter than those of the RY group (P < 0.05). A retrospective study found that the digestive tract reconstruction time of the U-RY group is 5 min shorter than that of the RY group, but the overall morbidity was not signi cantly different between groups (P < 0.05). 6 Because U-RY reduces the operation times for intestinal tract dissection and mesangial cutting, it may shorten the overall operation and digestive tract reconstruction times. U-RY also maintains the continuity and integrity of the intestinal tube such that the intestinal function of patients is quickly recovered after operation. [19][20] These results are similar to those of Yun et al. 21 In terms of quality of life The QLQ-C30 and QLQ-STO22 questionnaires are important scales for measuring the QoL of cancer patients; indeed, both are often used to evaluate the QoL of postoperative patients with gastric cancer. 14,[22][23][24] This study found that the physical function, role functioning, and global health status of the patients were improved and their pain symptoms were alleviated within 1-12 months after operation. This result suggests that resection of gastric tumor can improve the QoL of patients. Preoperative insomnia, anxiety, and emotional scores were generally high, likely because of the psychological factors of patients.
Earlier studies indicated that U-RY reconstruction preserves strong anti-biliary, pancreatic juice regurgitation capabilities and improves the QoL of patients after surgery. 4,25 In this study, although no signi cant difference in the incidence of re ux esophagitis was noted between the two groups (P > 0.05), the re ux symptom score of the U-RY group was signi cantly higher than that of the RY group. The differences found may be caused by differences in the operation steps, abdominal incision, and operative visual eld and the establishment of a jejunal closure point of input loop in the U-RY group (Figs 2). The length of the jejunal blind loop in the U-RY group was longer than that in the RY group, and a long blind loop could allow intestinal uid accumulation in the blind loop in the former, thereby increasing the incidence of alkaline re ux esophagitis. Whether the length of the jejunal blind loop is closely related to the incidence of re ux esophagitis requires further study.
Pain is a subjective feeling that is generally believed to be affected by postoperative abdominal adhesion, re ux symptoms, and other factors. 12 Both groups reported high pain scores 12 months after surgery, and the difference between groups was not statistically signi cant (P >0.05). The main manifestations of  Comparison of QoL items scores from preoperative baseline to postoperative 12 months between U-RY groups and RY groups. No recanalization was found at the occlusion site by endoscopy Figure 6 No recanalization was found at the occlusion site by upper gastroenterography