For tumors in the upper part of the stomach, PG or TG is required to obtain adequate surgical margins. Considering that the distal portion of the stomach is preserved, PG is considered to be less invasive and has greater functional preservation than TG, and many surgeons are actively applying PG to proximal gastric cancer. Researchers have attempted to determine the relationship between the extent of gastrectomy and the severity of postoperative symptoms and have come to different conclusions [[19],[20],[21],[22],[23],[24],[25],[26]]. This study retrospectively examined the relationship between the type of gastrectomy and postoperative quality of life in 55 patients treated with totally laparoscopic gastrectomy at our institution.
In this study, both TLPG-DT and TLTG are safe, feasible and minimally invasive like previously reported [14, 15]. Only one patient in the TLPG-DT group died after 43 months postoperatively due to non-surgery cause. All patients had no postoperative recurrence or progression of gastric cancer. Kaplan-Meier survival analysis (median follow-up period 30 months) showed no significant difference in overall survival between TLPG-DT and TLTG. However, three patients in the TLTG group underwent secondary surgery because of intestinal obstruction.
Larger tumor sizes and more lymph nodes collected after operation were found in TLTG group. Since we performed TLTG with D2 LNs dissection for advanced gastric tumor while TLPG-DT section with D1 + LNs dissection for early stage patients, these differences in pathological findings were expected. In terms of prognosis, there was no difference in 3-year OS between the TLPG-DT and TLTG groups, so D1 + lymph node dissection was sufficient for patients with EGC. In terms of intraoperative bleeding, postoperative complications, postoperative time to exhaustion, time out of bed, or days in the hospital, there were no significant differences between TLPG-DT and TLTG groups. The average surgery time of the former is about 5 minutes longer than the latter. The above indicates that there was no significant difference between the two groups from the point of view of perioperative safety.
Albumin and hemoglobin levels were used to evaluate the nutritional status of patients after surgery in our study. There was no significant difference of hemoglobin levels between TLPG-DT and TLTG group in the short-term postoperative period, while long-term results showed that the latter had lower hemoglobin levels as mild anemia (Mean ± SD:116.0 ± 16.32). Also, patients in the TLPG-DT group had higher albumin levels than those in the TLTG group in both the short-term and long-term outcomes. This is attributed to the fact that after total gastrectomy, patients are often deficient in iron and/or vitamin B12 due to malabsorption. The lack of gastric acid secretion and intrinsic factors can lead to malabsorption of these nutrients, resulting in clinically significant anemia or neuropathy. Similar to the findings of our study, Ji Yeon Park and his colleagues found that LPG with double-tract reconstruction appears superior in preventing vitamin B12 deficiency compared to LTG, particularly after 1 year after the surgery, although it offered little benefit in terms of postoperative body composition changes and QOL [27].
As for QOL, our study showed that patients in the TLPG-DT group had a slightly worse short-term QOL compared to the TLTG group. Within 6 months after surgery, patients in the TLPG-DT group had worse social functioning, more severe loss of appetite and symptoms of anxiety (Fig. 3). Obviously, several of these discrepant aspects were related to the psychological role of the patients and their emotional experience. It could be because patients undergoing PG feel that they have undergone a very complex surgery and are less likely to accept the operation. Another reason may be that PG is not as common as TG so that patients are more confused. Furthermore, it is also possible that we did not give more explanation to patients with PG before the surgery. In addition, patients in the TLPG-DT group paid ¥8,713 and ¥1,271 more than patients in the TLTG group in terms of total cost and consumables cost, respectively, which may have put an additional financial burden on the patients and thus caused psychological stress. No significant difference was found in the QOL of patients between the two groups after one year postoperatively.
By comparing the short-term results with the long-term results, we found that both groups of patients showed a satisfactory trend of change in some of the items. 48% and 53% of patients in the TLPG-DT and TLTG groups, respectively, experienced esophageal reflux in the short-term postoperative period, and changed to 36% and 16% in the long-term follow-up. (Fig. 4) Long-term outcomes showed significant improvement in esophageal reflux symptoms in both groups and the TLTG group performed better.
The high incidence of reflux esophagitis and anastomotic stricture after esophagogastric anastomosis is a major obstacle to the current widespread adoption of PG [28, 29]. This may be related to surgical anastomotic scar contracture, decreased elasticity, and weak dilatation, resulting in the patient's inability to digest food in a timely manner after eating. Compared with esophagogastrostomy, double-tract reconstruction could better prevent reflux esophagitis and improve QOL without scarifying perioperative safety or 3-year OS [[30],[31],[32]]. In our study, 32% of patients in the TLPG-DT group had dysphagia in the short-term outcome, which became 13% in the long-term follow-up. A significant reduction in the proportion of patients with distant postoperative dysphagia could be found. Our postoperative aqueous angiogram showed that the patient was predominantly single-channel, i.e., esophagus-jejunum or esophagus-jejunum loop-gastric, in the short postoperative period. The additional anastomosis recovery made the patient's swallowing discomfort more pronounced. In the long-term follow-up, the residual gastric pathway gradually came into play dominantly, achieving a pathway closer to natural digestion or a dual pathway to digest food, so the symptoms of dysphagia were improved significantly. Overall, TLPG with double-tract reconstruction is satisfactory in terms of QOL.
The strength of this study is that the patients included in the study were all treated at the same institution following the same treatment process, so the differences observed are likely due to the surgery itself rather than differences between institutional practices. However, there are some limitations to this study. First, it was based on a retrospective analysis, which may lead to selection bias, with a relatively small number of patients enrolled in each group. Second, the retrospective analyses need to rely on the data we have collected and followed up. However, the duration of follow-up and the assessment of function and quality of life varies slightly between patients. For this reason, we set up dedicated staff to collect follow-up information and to help patients understand and complete the questionnaire. In addition, patients' responses to the EORTC QLQ-C30 and QLQ-STO22 questionnaires contain some subjectivity, and there may be some variation in the state and mood of different patients when answering the questionnaires. In order to minimize the variation caused by the subjectivity of patients, we analyzed both short-term and long-term objective indicators such as albumin and hemoglobin to create a certain balance. Therefore, we hope to complete prospective cohort studies with larger sample sizes and longer follow-up times in the future to confirm our findings.