The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of Weifang People's Hospital . All patients consented to the data being used for research when receiving treatment. The inclusion criteria were as follows: gastroscopic biopsy-confirmed adenocarcinoma of the stomach, imaging confirmation that the tumor is located in the middle and upper portions of the stomach or esophagogastric junction, and CTNM stage Ⅱ-Ⅲ. The exclusion criteria were as follows: received neoadjuvant radiotherapy and chemotherapy prior to operation, failure to achieve R0 resection, and gastric stump cancer.
The study protocol was approved by the research ethics committee of Weifang People’s Hospital. Written informed consent was obtained from all patients prior to operation.
All patients underwent laparoscopic-assisted total gastrectomy with D2 lymphadenectomy on the basis of Japanese gastric cancer treatment guidelines.11 After laparoscopic lymph node dissection, a small (i.e., approximately 10 cm) incision was made from the upper abdomen, the esophagus was cut off at approximately 2–5 cm from the upper edge of the lesion, and the specimen was removed. Digestive tract reconstruction was performed in vitro.
U-RY and RY reconstructions were established by using mechanical staples. In the U-RY group, an esophagojejunostomy was established between the lower esophagus and jejunum 45 cm distal to the ligament of Treitz after total gastrectomy. Then, a side-to-side jejunojejunostomy was established between the afferent and efferent jejunal limbs approximately 40 cm distal to the esophagojejunostomy site and 20 cm distal to the ligament of Treitz. Finally, the jejunal lumen was occluded using the four-row (knifeless) stapler method at a site 3–5 cm proximal to the esophagojejunostomy. In the R-Y group,
the jejunum was divided and closed using a 60 mm linear 20 cm distant from the Treitz ligament. Next, an esophagojejunostomy was established between the lower esophagus and distal jejunum with a 25 mm circular stapler in an end-to-side fashion. A side-to-side jejunojejunostomy was established between the proximal and distal jejunums 40 cm below the esophagojejunostomy.
All operations on patients with gastric cancer were performed by the same surgical team. The two methods of digestive tract reconstruction are depicted in Figs. 1,2,3.
Observation indicators and evaluation standards
The operation time, digestive tract reconstruction time, intraoperative blood loss, first 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 fields, including five functional fields (i.e., physical, role, cognitive, emotional, and social), three symptom fields (i.e., pain, fatigue, nausea and vomiting), one global health status field, and six single items(each as a field, i.e., Appetite loss, Insomnia, Constipation, Dyspnea, Diarrhea, Financial difficulties).13 The EORTC QLQ-STO22 questionnaire consists of 22 items that can be divided into 9 areas: five symptom areas (i.e., dysphagia, pain, eating restrictions, reflux 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 difficulties, 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.
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 chi-squared or Fisher’s exact test. Here, P < 0.05 was considered statistically significant.