t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Quality of life after total and subtotal gastrectomy for gastric carcinoma Y.M. Goh*, C. Gillespie, G. Couper, S. Paterson-Brown Department of General and Upper Gastro-Intestinal Surgery, The Royal Infirmary Of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
article info
abstract
Article history:
Background: There remains debate as to whether quality of life (QoL) is better for patients
Received 23 April 2014
following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar
Received in revised form
survival rates provided an R0 resection is performed and in many series the morbidity and
27 June 2014
mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in
Accepted 8 July 2014
patients after TG and SG for cancer.
Available online 7 August 2014
Method: All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for
Keywords:
Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the
Quality of life
gastric module (QLQ-STO22).
Gastrectomy
Results: From a total of 261 patients who had undergone TG or SG in the study period, 91
EORTC
were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group. Conclusion: This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG. © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Gastric cancer is the second most common cancer worldwide with an estimated incidence of 870 0001 per year with nearly two-thirds of cases occurring in developing countries.2 In Scotland, the incidence of gastric cancer has decreased by half over the past 23 years from 1985 to 2008 and is more prevalent in the West of Scotland.3 Curative gastrectomy can only be achieved by the complete removal of the tumour with histological confirmation of the
tumour free R0 resection margin and associated lymph nodes. Both neo-adjuvant chemotherapy4 and D2 lymphadenectomy5 can improve survival provided an R0 resection has been completed. Although the position of the tumour will dictate the necessity for TG, there are patients with more distally placed tumours where the value of TG over SG with regard for ‘chance of cure’ versus long term morbidity is unclear provided an adequate lymph node dissection and R0 clearance can be accomplished. Advocates of TG argue that it can be performed safely with low operative mortality and morbidity6 while at the same time reduce the risk of incomplete proximal
* Corresponding author. Apartment 222, The Quadrangle, 1 Lower Ormond Street, Manchester, M1 5QE, United Kingdom. Tel.: þ44 7515017372. E-mail address: [email protected] (Y.M. Goh). http://dx.doi.org/10.1016/j.surge.2014.07.002 1479-666X/© 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
268
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
resection margin and eliminate the risk of a second carcinoma in the gastric remnant. However advocates of SG would say that an increase in the risk of mortality and morbidity, reduction in nutritional deficiencies and a worse QoL might be a poor price to pay if TG does not provide any advantage in terms of long-term survival. There is no doubt that preservation of some proximal stomach appears to be associated with some improvement in gastrointestinal symptoms when compared to TG,7 while the use of some form of jejunal pouch after TG does appear to be associated with improved symptoms.8 This study was therefore carried out in order to assess the QoL in patients after TG and SG for gastric carcinoma.
Methods and materials All surviving patients who had undergone potentially curative gastrectomy, either SG (including) or TG (without pouch formation), for gastric carcinoma between 1994 and 2009 were identified from a prospectively collected database. SG included some patients undergoing Bilroth I and Bilroth II (for small distal tumours) the majority had Roux-en-Y reconstruction. All patients underwent a D2 lymphadenectomy and in the Bilroth I reconstruction patients the whole lesser curve was resected with the greater curve used for reconstruction. The decision on whether to proceed with TG or SG was left to the decision of the surgeon and was primarily based on findings at operation. These patients were invited to complete two questionnaires provided by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life (QoL) group: the core questionnaire (QLQ-C30 v.3) and the gastric specific module questionnaire (QLQSTO22). The EORTC QLQ-C30 comprises 30 items and is composed of 15 scales including global health status and QoL, five functional scales (physical, role, emotional, cognitive and social) and nine symptom scales and single items (fatigue, nausea and vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhoea and financial difficulties). The EORTC QLQ-STO22 comprises of nine scales including dysphagia, pain, reflux symptoms, eating restrictions, anxiety, dry mouth, taste, body image and hair loss. The QoL assessment is based on the responder's answers to these questions on a self-completed questionnaire. These raw scores are transformed into linear scores from 0 to 100 as per the EORTC QLQ-30 Scoring Manual and Addendum scoring instructions for the EORTC gastric module QLQSTO22. A high score for the global health status and QoL and functional scale from the EORTC QLQ-C30 represents a high QoL. A high score for a symptom scale or single item represents a low QoL. For the EORTC QLQ-STO22 a high score for a scale represents a low QoL. The results of these scores were entered into a statistical package, the Predictive Analytical SoftWare (PASW) for further analysis. The scored results of the SG and TG groups were analysed using an independent samples t-test and the global health status was analysed with a one way analysis of variance (ANOVA) to compare the difference in QoL between the two procedures.
Results From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded to the questionnaire. Overall demographics are shown in Table 1. The quality of life results from the core questionnaire and gastric specific module are shown in Figs. 1 and 2. There is a higher global health status and function in the SG group than the TG group. Patients in the TG group report a higher symptom score, which is on average 37.1% higher than the SG group. The results from the gastric specific module demonstrate lower symptom scores in the SG than the TG group except for anxiety at 17.9% higher in the SG than TG group. Statistical analysis using an independent samples t-test demonstrates that there is no significant difference in all parameters measured in the core and gastric specific module questionnaire with the exception of dysphagia and eating restrictions that were significantly higher in the TG than SG group. These symptoms were reported in 23% of all patients who have undergone either TG or SG in the study period. Analysis of variance comparing global health status in both groups shows no significant differences between TG and SG with a p value of 0.9999 and F value of 0.0002.
Discussion Quality of life is often a controversial subject in patients who have had surgery for gastric cancer. It has been suggested that the QoL represents the functional effect of a disease and its treatment,9 in other words how it is perceived and the extent to which it affects the life of a patient. QoL is acknowledged to be an important endpoint in patients in addition to oncologic outcomes and safety issues.10,11 Understanding the possible differences in QoL after TG and SG will not only influence clinical decision making regarding the decision for surgery, but also which procedure is indicated.12 Quality of life outcomes is difficult to assess and it is for this reason the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) was used in this study because of its practicality and validity in measuring quality of life in patients.13 The addition of the gastric specific module (QLQ-STO22) ensures a more accurate assessment of QoL in patients with gastric cancer by measuring other QoL parameters that are not included or sufficiently covered by the core questionnaire hence increasing the sensitivity of the QoL measurements in patients with gastric cancer.14 Although this is a relatively small study, it has demonstrated no significant difference in overall QoL in patients Table 1 e Patient demographics of those who responded to the questionnaire. Number of patients Gender Mean age (years) Procedure
Male Female TG SG
53 30 23 73 (39e90) 25 (47%) 28 (53%)
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
269
Fig. 1 e Mean scores and 95% confidence interval for the QLQ C-30 Core Questionnaire for both the TG and SG groups.
Fig. 2 e Mean scores and 95% confidence interval for the QLQ STO-22 gastric specific module for both the TG and SG groups.
after TG or SG. This differs from other studies which have shown a better QoL in patients after SG than TG due to reduced dumping and oesophageal reflux, with better food intake and weight gain.15e17 It has been recognised that the construction of a gastric substitute is also associated with better food intake and weight increase in the early postoperative period although these advantages are less with prolonged follow up.18 However, in our study, when each parameter of QoL is measured separately, eating restrictions and dysphagia are shown to be significantly worse in patients who have had TG compared to SG. One study looking at 43 patients at a mean of 3 years post surgery showed that patients who had TG had to eat more often, ingested fewer calories and lost more weight than those who had undergone SG.19 Despite a significant difference in eating restrictions in patients after TG compared to SG in our study, these patients did not report a significant effect on their overall QoL. In this exploratory study no differences between TG and SG were observed, but a larger study is needed to explore this
further. It is possible that some form of gastric substitute, such as jejunal interposition, might also be helpful in reducing eating restrictions following TG in the longer term.
Acknowledgements We would like to thank Professor Jane Blazeby for her advice on using the EORTC core questionnaire (QLQ-C30 v.3) and the gastric module (QQ-STO22). No external writing assistance was used for this manuscript.
references
1. World Health Organisation. Media centre. World cancer report; 2003 [Cited 2012 Dec 30] Available from: http://www.who.int/ mediacentre/news/releases/2003/pr27/en/.
270
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
2. World Health Organisation. Cancer: the growing burden. The World health report; 1997 [cited 2012 Dec 30] Available from: http://www.who.int/whr/1997/media_centre/executive_ summary1/en/index7.html. 3. Information Services Division. NHS Scotland. stomach cancer. Information and statistics; 2010 [Cited 2012 Dec 30] Available from: http://www.isdscotland.org/isd/1503.html#Cancer% 20of%20the%20stomach. 4. Cunningham D, Allum WH, Stenning SP, Weeden S. Perioperative chemotherapy in operable gastric and lower oesophageal cancer: final results of a randomised controlled trial (the MAGIC trial). J Clin Oncol 2005;23:308. 5. Marubini E, Bozzetti F, Miceli R, Bonfanti G, Gennari L. Lymphadenectomy in gastric cancer: prognostic role and therapeutic implications. Eur J Surg Oncol 2002;28:406e12. 6. Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Crose N, et al. Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicentre Italian randomised trial. The Italian Gastrointestinal Tumor Study Group. Ann Surg Nov 1997;226(5):613e20. 7. Svedlund J, Sullivan M, Liedman B, Lundell L, Sjodin I. Quality of life after gastrectomy for gastric carcinoma: controlled study of reconstructive procedures. World J Surg 1997;21(4):422e33. 8. Herfarth C, Schlaug P, Buhl K. Surgical procedures for gastric substitution. World J Surg 1987;11(6):689e98. 9. Schipper H, Clinch J, Powell V. Definitions and conceptual issues. In: Quality of life assessments in clinical trials. New York: Raven Press; 1990. pp. 11e24. 10. Akoh JA, Machintyre IM. Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970. Br J Surg 1970;79:293e9.
11. Maruyama K, Okabayashi K, Kninoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. World J Surg 1987;11(4):418e25. 12. Langenhoff BS, Krabbe P, Wobbes T, Ruers T. Quality of life as an outcome measure in surgical oncology. Br J Surg 2001;88(5):643e52. 13. Kaasa S, Bjordal K, Aaronson N, Moum T, Wist E, Hagen S, et al. The EORTC Core quality of life questionnaire (QLQ-C30): validity and reliability when analysed with patients treated with palliative radiotherapy. Eur J Cancer 1995;31A(13e10):2260e3. 14. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The european organisation for research and treatment on cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85(5):365e76. 15. Bozzetti F. Total versus subtotal gastrectomy in cancer of the distal stomach: facts and fantasy. Eur J Surg Oncol 1992;18(6):572e9. 16. Lehnert T, Buhl K. Techniques of reconstruction after total gastrectomy or cancer. Br J Surg 2004;91(5):528e39. 17. Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Gennari L. Subtotal versus total gastrectomy for gastric cancer. Five year survival rates in a multicenter randomised Italian trial. Ann Surg 1999;230(2):170e8. 18. Davies J, Johnston D, Sue-Ling H, May J, Griffith J, Miller G, et al. Total or subtotal gastrectomy for gastric carcinoma? A study of quality of life. World J Surg 1998;22(10):1048e55. 19. Bozzetti F, Ravera E, Cozzaglio L, Dossena G, Agradi E, Bonfanti G, et al. Comparison of nutritional status after total or subtotal gastrectomy. Nutrition 1990;6(5):371e5.
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Quality of life after total and subtotal gastrectomy for gastric carcinoma Y.M. Goh*, C. Gillespie, G. Couper, S. Paterson-Brown Department of General and Upper Gastro-Intestinal Surgery, The Royal Infirmary Of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
article info
abstract
Article history:
Background: There remains debate as to whether quality of life (QoL) is better for patients
Received 23 April 2014
following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar
Received in revised form
survival rates provided an R0 resection is performed and in many series the morbidity and
27 June 2014
mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in
Accepted 8 July 2014
patients after TG and SG for cancer.
Available online 7 August 2014
Method: All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for
Keywords:
Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the
Quality of life
gastric module (QLQ-STO22).
Gastrectomy
Results: From a total of 261 patients who had undergone TG or SG in the study period, 91
EORTC
were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group. Conclusion: This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG. © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Gastric cancer is the second most common cancer worldwide with an estimated incidence of 870 0001 per year with nearly two-thirds of cases occurring in developing countries.2 In Scotland, the incidence of gastric cancer has decreased by half over the past 23 years from 1985 to 2008 and is more prevalent in the West of Scotland.3 Curative gastrectomy can only be achieved by the complete removal of the tumour with histological confirmation of the
tumour free R0 resection margin and associated lymph nodes. Both neo-adjuvant chemotherapy4 and D2 lymphadenectomy5 can improve survival provided an R0 resection has been completed. Although the position of the tumour will dictate the necessity for TG, there are patients with more distally placed tumours where the value of TG over SG with regard for ‘chance of cure’ versus long term morbidity is unclear provided an adequate lymph node dissection and R0 clearance can be accomplished. Advocates of TG argue that it can be performed safely with low operative mortality and morbidity6 while at the same time reduce the risk of incomplete proximal
* Corresponding author. Apartment 222, The Quadrangle, 1 Lower Ormond Street, Manchester, M1 5QE, United Kingdom. Tel.: þ44 7515017372. E-mail address: [email protected] (Y.M. Goh). http://dx.doi.org/10.1016/j.surge.2014.07.002 1479-666X/© 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
268
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
resection margin and eliminate the risk of a second carcinoma in the gastric remnant. However advocates of SG would say that an increase in the risk of mortality and morbidity, reduction in nutritional deficiencies and a worse QoL might be a poor price to pay if TG does not provide any advantage in terms of long-term survival. There is no doubt that preservation of some proximal stomach appears to be associated with some improvement in gastrointestinal symptoms when compared to TG,7 while the use of some form of jejunal pouch after TG does appear to be associated with improved symptoms.8 This study was therefore carried out in order to assess the QoL in patients after TG and SG for gastric carcinoma.
Methods and materials All surviving patients who had undergone potentially curative gastrectomy, either SG (including) or TG (without pouch formation), for gastric carcinoma between 1994 and 2009 were identified from a prospectively collected database. SG included some patients undergoing Bilroth I and Bilroth II (for small distal tumours) the majority had Roux-en-Y reconstruction. All patients underwent a D2 lymphadenectomy and in the Bilroth I reconstruction patients the whole lesser curve was resected with the greater curve used for reconstruction. The decision on whether to proceed with TG or SG was left to the decision of the surgeon and was primarily based on findings at operation. These patients were invited to complete two questionnaires provided by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life (QoL) group: the core questionnaire (QLQ-C30 v.3) and the gastric specific module questionnaire (QLQSTO22). The EORTC QLQ-C30 comprises 30 items and is composed of 15 scales including global health status and QoL, five functional scales (physical, role, emotional, cognitive and social) and nine symptom scales and single items (fatigue, nausea and vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhoea and financial difficulties). The EORTC QLQ-STO22 comprises of nine scales including dysphagia, pain, reflux symptoms, eating restrictions, anxiety, dry mouth, taste, body image and hair loss. The QoL assessment is based on the responder's answers to these questions on a self-completed questionnaire. These raw scores are transformed into linear scores from 0 to 100 as per the EORTC QLQ-30 Scoring Manual and Addendum scoring instructions for the EORTC gastric module QLQSTO22. A high score for the global health status and QoL and functional scale from the EORTC QLQ-C30 represents a high QoL. A high score for a symptom scale or single item represents a low QoL. For the EORTC QLQ-STO22 a high score for a scale represents a low QoL. The results of these scores were entered into a statistical package, the Predictive Analytical SoftWare (PASW) for further analysis. The scored results of the SG and TG groups were analysed using an independent samples t-test and the global health status was analysed with a one way analysis of variance (ANOVA) to compare the difference in QoL between the two procedures.
Results From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded to the questionnaire. Overall demographics are shown in Table 1. The quality of life results from the core questionnaire and gastric specific module are shown in Figs. 1 and 2. There is a higher global health status and function in the SG group than the TG group. Patients in the TG group report a higher symptom score, which is on average 37.1% higher than the SG group. The results from the gastric specific module demonstrate lower symptom scores in the SG than the TG group except for anxiety at 17.9% higher in the SG than TG group. Statistical analysis using an independent samples t-test demonstrates that there is no significant difference in all parameters measured in the core and gastric specific module questionnaire with the exception of dysphagia and eating restrictions that were significantly higher in the TG than SG group. These symptoms were reported in 23% of all patients who have undergone either TG or SG in the study period. Analysis of variance comparing global health status in both groups shows no significant differences between TG and SG with a p value of 0.9999 and F value of 0.0002.
Discussion Quality of life is often a controversial subject in patients who have had surgery for gastric cancer. It has been suggested that the QoL represents the functional effect of a disease and its treatment,9 in other words how it is perceived and the extent to which it affects the life of a patient. QoL is acknowledged to be an important endpoint in patients in addition to oncologic outcomes and safety issues.10,11 Understanding the possible differences in QoL after TG and SG will not only influence clinical decision making regarding the decision for surgery, but also which procedure is indicated.12 Quality of life outcomes is difficult to assess and it is for this reason the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) was used in this study because of its practicality and validity in measuring quality of life in patients.13 The addition of the gastric specific module (QLQ-STO22) ensures a more accurate assessment of QoL in patients with gastric cancer by measuring other QoL parameters that are not included or sufficiently covered by the core questionnaire hence increasing the sensitivity of the QoL measurements in patients with gastric cancer.14 Although this is a relatively small study, it has demonstrated no significant difference in overall QoL in patients Table 1 e Patient demographics of those who responded to the questionnaire. Number of patients Gender Mean age (years) Procedure
Male Female TG SG
53 30 23 73 (39e90) 25 (47%) 28 (53%)
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
269
Fig. 1 e Mean scores and 95% confidence interval for the QLQ C-30 Core Questionnaire for both the TG and SG groups.
Fig. 2 e Mean scores and 95% confidence interval for the QLQ STO-22 gastric specific module for both the TG and SG groups.
after TG or SG. This differs from other studies which have shown a better QoL in patients after SG than TG due to reduced dumping and oesophageal reflux, with better food intake and weight gain.15e17 It has been recognised that the construction of a gastric substitute is also associated with better food intake and weight increase in the early postoperative period although these advantages are less with prolonged follow up.18 However, in our study, when each parameter of QoL is measured separately, eating restrictions and dysphagia are shown to be significantly worse in patients who have had TG compared to SG. One study looking at 43 patients at a mean of 3 years post surgery showed that patients who had TG had to eat more often, ingested fewer calories and lost more weight than those who had undergone SG.19 Despite a significant difference in eating restrictions in patients after TG compared to SG in our study, these patients did not report a significant effect on their overall QoL. In this exploratory study no differences between TG and SG were observed, but a larger study is needed to explore this
further. It is possible that some form of gastric substitute, such as jejunal interposition, might also be helpful in reducing eating restrictions following TG in the longer term.
Acknowledgements We would like to thank Professor Jane Blazeby for her advice on using the EORTC core questionnaire (QLQ-C30 v.3) and the gastric module (QQ-STO22). No external writing assistance was used for this manuscript.
references
1. World Health Organisation. Media centre. World cancer report; 2003 [Cited 2012 Dec 30] Available from: http://www.who.int/ mediacentre/news/releases/2003/pr27/en/.
270
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 2 6 7 e2 7 0
2. World Health Organisation. Cancer: the growing burden. The World health report; 1997 [cited 2012 Dec 30] Available from: http://www.who.int/whr/1997/media_centre/executive_ summary1/en/index7.html. 3. Information Services Division. NHS Scotland. stomach cancer. Information and statistics; 2010 [Cited 2012 Dec 30] Available from: http://www.isdscotland.org/isd/1503.html#Cancer% 20of%20the%20stomach. 4. Cunningham D, Allum WH, Stenning SP, Weeden S. Perioperative chemotherapy in operable gastric and lower oesophageal cancer: final results of a randomised controlled trial (the MAGIC trial). J Clin Oncol 2005;23:308. 5. Marubini E, Bozzetti F, Miceli R, Bonfanti G, Gennari L. Lymphadenectomy in gastric cancer: prognostic role and therapeutic implications. Eur J Surg Oncol 2002;28:406e12. 6. Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Crose N, et al. Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicentre Italian randomised trial. The Italian Gastrointestinal Tumor Study Group. Ann Surg Nov 1997;226(5):613e20. 7. Svedlund J, Sullivan M, Liedman B, Lundell L, Sjodin I. Quality of life after gastrectomy for gastric carcinoma: controlled study of reconstructive procedures. World J Surg 1997;21(4):422e33. 8. Herfarth C, Schlaug P, Buhl K. Surgical procedures for gastric substitution. World J Surg 1987;11(6):689e98. 9. Schipper H, Clinch J, Powell V. Definitions and conceptual issues. In: Quality of life assessments in clinical trials. New York: Raven Press; 1990. pp. 11e24. 10. Akoh JA, Machintyre IM. Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970. Br J Surg 1970;79:293e9.
11. Maruyama K, Okabayashi K, Kninoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. World J Surg 1987;11(4):418e25. 12. Langenhoff BS, Krabbe P, Wobbes T, Ruers T. Quality of life as an outcome measure in surgical oncology. Br J Surg 2001;88(5):643e52. 13. Kaasa S, Bjordal K, Aaronson N, Moum T, Wist E, Hagen S, et al. The EORTC Core quality of life questionnaire (QLQ-C30): validity and reliability when analysed with patients treated with palliative radiotherapy. Eur J Cancer 1995;31A(13e10):2260e3. 14. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The european organisation for research and treatment on cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85(5):365e76. 15. Bozzetti F. Total versus subtotal gastrectomy in cancer of the distal stomach: facts and fantasy. Eur J Surg Oncol 1992;18(6):572e9. 16. Lehnert T, Buhl K. Techniques of reconstruction after total gastrectomy or cancer. Br J Surg 2004;91(5):528e39. 17. Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Gennari L. Subtotal versus total gastrectomy for gastric cancer. Five year survival rates in a multicenter randomised Italian trial. Ann Surg 1999;230(2):170e8. 18. Davies J, Johnston D, Sue-Ling H, May J, Griffith J, Miller G, et al. Total or subtotal gastrectomy for gastric carcinoma? A study of quality of life. World J Surg 1998;22(10):1048e55. 19. Bozzetti F, Ravera E, Cozzaglio L, Dossena G, Agradi E, Bonfanti G, et al. Comparison of nutritional status after total or subtotal gastrectomy. Nutrition 1990;6(5):371e5.
![[Quality of life after gastrectomy and subtotal distal resection for gastric carcinoma].](/assets/img/hold.png)
