Assessment of Postoperative Symptoms After Laparoscopy-Assisted Distal Gastrectomy for Stage I Gastric Cancer

Abstract

Laparoscopic gastrectomy has the advantage of early recovery at the initial phase after surgery. However, there are only few reports of mid- or long-term observations of patients' quality of life. In all, 254 Stage IA or IB [laparoscopy-assisted distal gastrectomy (LADG): 177, open distal gastrectomy (ODG): 77] patients were enrolled. Heart burn, diarrhea, abdominal pain, amount of food intake, and body weight of each patient were investigated at 1 month, 3 months, 6 months, and 1 year after surgery. Recovery of the amount of oral intake for the LADG group occurred earlier than for the ODG group; significant differences were seen at months 1 and 6 postoperatively. A significantly lower incidence of diarrhea was observed in the LADG group at months 6 and 12 postoperatively. Early recovery of the amount of food intake and fewer incidences of diarrhea were shown to have mid-term merits for postgastrectomy symptoms.

Laparoscopic gastrectomy is well known as a less invasive surgery, which provides an early recovery from the pain, bowel paralysis, and hematologic parameters. However, these well-examined objects belong to the recovery by the day.¹⁻³ On the other hand, the fluctuation of the frequency of heart burn, diarrhea and abdominal pain after eating, amount of oral intake, and body weight loss persist for months. So these subjects belong to the recovery by the month. And only a few studies about these subjects after laparoscopic gastrectomy compared with open gastrectomy.^4,5 Therefore, it is unclear whether laparoscopic gastrectomy has merits for improved mid- or long-term quality of life (QOL). In this study, we observed these postgastrectomy symptoms during the first year after surgery, and compared the changeover between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG).

Patients and Methods

This study was a retrospective study. In all, 254 Stage IA or IB gastric cancer patients who underwent distal gastrectomy with regional lymph node dissection between January 2004 and December 2008, who were not administered any anticancer drug, and had not shown any recurrence to date, were enrolled in this study. Each patient opted for LADG or ODG after they provided informed consent. In these 254 cases, LADG was performed in 177 and ODG was performed in 77. The rate of LADG was gradually increased year by year as LADG became popular in Japan (Fig. 1).

Fig. 1.

Changes of the number of laparoscopy-assisted distal gastrectomy and open distal gastrectomy.

All patients were scheduled for visits at 1 month, 3 months, 6 months, and 1 year after surgery; they completed verbal questionnaires about frequency of nausea or heart burn, water diarrhea, and abdominal pain after taking food (dumping syndrome), and recorded the amount of food intake compared with preoperative state, and body weight. The number of days that these symptoms occurred per week was asked. Nausea, heart burn, and abdominal pain were regarded positively when the patients realize. Diarrhea was recorded in cases of watery stools. To compare postoperative symptoms between LADG and ODG, we examined the proportion of patients who had symptoms more than three days per week. Body weight was evaluated as a percentage compared with preoperative weight.

Routine prophylactic antacids or digestive drugs were not administered. Occasional binding medicines were administered for troublesome diarrhea. Proton pomp inhibitors were offered for severe heart burn; however, no patient needed this treatment.

The extent of lymph node dissection and degree of cancer stage are described in accordance with the Japanese Classification of Gastric Carcinoma, 2nd edition.⁶

Surgical procedures

In ODG, a 20-cm upper-midline laparotomy incision was made and electrocautery was used for dissection. In LADG, one camera port was inserted in the subumbilical region, two 5-mm ports in the bilateral hypochondriac region, and two 12-mm ports in the bilateral flank region. A 4-cm upper-midline abdominal incision was made to extract and reconstruct the stomach; laparoscopic coagulating shears were used for dissection. In both procedures, the left and right gastro-epiploic arteries, and right and left gastric arteries were dissected. Posterior and anterior blanches of vagus nerves were dissected to ease for lymph node dissections. Billroth I reconstruction was the main procedure used in this series; however, if Billroth I was difficult (e.g., small gastric remnant or fatty cases), we chose Roux-en-Y reconstruction with the length of Roux limb being 40 cm.

Statistical analysis

The t-test and Pearson's chi-square test were used for statistical investigations. SPSS 16.0 for Windows (SPSS Inc., Chicago, IL, USA) statistical software was used for statistical analyses. Differences were considered significant at a P value < 0.05.

Results

Background of patients

Gender, age, body mass index, American Society of Anesthesiology classification, and operative time were not significantly different between the LADG and ODG groups. Blood loss was significantly less (P = 0.000) in the LADG group than in the ODG group. Methods of reconstructions and degree of lymph node dissection were not significantly different between the two groups. Postoperative complications were significantly fewer in the LADG group than in the ODG group. Stages were not significantly different between the two groups (Table 1).

Table 1.

Patient's background

Comparison of postoperative symptoms after LADG and ODG

Body weight loss was lower in the LADG group than in the ODG group; however, no significant difference was seen at any point in time (Fig. 2A). The patients in the LADG group recovered their amount of oral intake earlier than those in the ODG group; significant differences were seen at 1 month and 6 months after surgery (Fig. 2B).

Fig. 2.

Postoperative conversions of body weight and food intake compared with preoperative states. A: Conversion of body weight; B: Conversion of the amount of food intake.

The frequency of nausea declined earlier in the ODG group than in the LADG group, however, no significant difference was observed at all times (Fig. 3A). To the contrary, the frequency of abdominal pain declined earlier in the LADG group than in the ODG group; in this factor as well, no significant difference was observed at all times (Fig. 3B). As for frequency of water diarrhea, the LADG group showed a lower incidence than the ODG group at all times, and a significantly lower incidence was observed in the LADG group at 6 and 12 months after surgery (Fig. 3C).

Fig. 3.

Proportion of patients who had postgastrectomy disorders two days or more per week. A: Conversion of the incidence of upper abdominal discomfort; B: Conversion of the incidence of diarrhea; C: Conversion of the incidence of abdominal pain.

Discussion

Postgastrectomy symptoms involve a decreasing amount of oral intake and body weight loss, resulting from a lower ability to store food. The nausea, abdominal pain, and diarrhea are caused by bloating and abnormal peristalsis of remnant stomach or intestinal tissue.⁷⁻⁹ There have been many reports showing the less invasive nature of LADG in the short term; however, there have been only two mid- and long-term studies about these postgastrectomy symptoms to date.¹⁻⁵ The former was a randomized control study at a single institution that compared QOL during 3 months postoperation between LADG and ODG, and concluded that QOL after LADG was better than after ODG in both its physical and mental aspects.⁴ In this study, symptoms of fatigue, pain, appetite loss, sleep disturbance, dysphasia, gastro-esophageal reflex, dietary restriction, anxiety, dry mouth, and body image were reported significantly better than in the LADG group compared with the ODG group.⁴ They could not mention definite reason of these effects; however, less adhesion was supposed to be one of the reasons.⁴ The latter was a retrospective study aided by a questionnaire that compared long-term QOL after LADG (mean followup period, 99.3 months) and ODG (mean followup period, 97 months), and concluded that fewer incidences of adhesive small bowel obstruction were observed after LADG than after ODG.⁵ This report also advocates the merit of lesser adhesion of LADG.

We researched the change over the time of postgastrectomy symptoms for a year, because postgastrectomy symptoms and body weight loss become stable after 6 months after surgery. The amount of food intake after gastrectomy is usually lower immediately after surgery and recovers gradually. In this study, earlier recovery of the amount of food intake was seen in LADG as compared to ODG. Comparing the recovery pattern of the amount of food intake between the two groups, LADG patients achieved a larger amount of food intake than ODG patients during the early phase, and recovered 80% of their pre-operative state at 6 months after surgery. However, ODG patients required 1 year for recovery before reaching the same level as that of LADG patients. The mechanism by which the amount of food intake improves is very complex: it involves multiple factors, such as remnant stomach and intestinal tissue, and the patient's mental state.⁴ In this study, however, the extent of resected stomach, vessels, and nerves were identical in LADG and ODG; thus, the main causes of difference in food intake were assumed to be intestinal. On the other hand, although body weight loss was lower in the LADG group than in the ODG group, no significant difference was observed. From outpatient interviews, we assume that patients who had increased their food intake recovered their normal meal behavior (3 meals a day). Moreover, this may be the reason that no significant difference was observed in recovery of body weight between the two groups. In addition, in outpatient interviews, most patients felt nausea after they ate a heavy meal. The frequency of nausea was higher in the LADG group, which may be an adverse effect of the early recovery of the amount of food intake in this group.

After gastrectomy, influx of insufficient digested food into the intestine, dissection of vagus nerves, adhesion, and other factors often cause diarrhea or abdominal pain after eating a meal.⁷ In this study, the frequency of diarrhea in the LADG group was always lower, and significant differences were observed 6 and 12 months postsurgery. Moreover, the frequency of abdominal pain was also lower (but not significantly) in the LADG group. These observations suggest that the peristalsis of intestine after the food intake following LADG is at a level closer to normal than that after ODG. Peristalsis is influenced by multiple factors that include adhesion, patient's mental state, and eating speed.⁷ We also expect the main reason of those differences was lesser adhesion of LADG, because there was no difference in surgical techniques between in the LADG group and in the ODG group except laparoscopic or open approach.^4,5 A study of postoperative symptoms or QOL like our study should be counted as a Hawthorne effect. However, we explained to the patients that only cosmetic benefit and early-phase recovery were the merits of LADG; no mid- or long-term merits were explained. So we consider Hawthorne effect did not significantly influence patients' mental factors.

In conclusion, the early recovery of the amount of food intake and lower incidence of diarrhea were shown to be mid-term merits for QOL after LADG as compared with ODG. The detailed reasons are unclear; however, fewer adhesions following LADG may be one of the reasons.