- Email: [email protected]
Long-term quality of life and symptoms of patients who underwent esophageal reconstruction employing intestinal pedicle grafts
The American Journal of Surgery 187 (2004) 422– 426
Scientific paper
Long-term quality of life and symptoms of patients who underwent esophageal reconstruction employing intestinal pedicle grafts Krzysztof Grabowski, M.D., Ph.D.a, Mariusz Kusztal, M.D.b,* b
a Department of Gastrointestinal Surgery, Wroclaw Medical University, Wroclaw, Poland Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, ul. Traugutta 57/59, 50-417 Wroclaw, Poland
Manuscript received October 7, 2002; revised manuscript May 18, 2003
Abstract Background: This study was conducted to assess the long-term quality of life (QOL) and symptoms experienced by patients who underwent esophageal reconstruction. Methods: We invited by mail 64 patients (group 1) and 400 subjects from the general population (group 2) to complete a two-part questionnaire regarding esophageal function and QOL (RAND 36). Results: In all 39 group 1 and 114 group 2 subjects qualified for the final analysis. In the majority esophageal symptoms appeared directly after the operation. Symptoms of problems were choking (51%), burp (38%), and postprandial fullness (36%). Nineteen patients (49%) reported other comorbidities. Group 1 reported poorer QOL (P ⬍0.01) in 2 of 8 QOL areas by comparision with group 2. There were no correlations between QOL scales and type of intestinal pedicle grafts or time after esophageal reconstruction. Conclusions: Long-term QOL assessed by the patients themselves in general seems to be similar to that of the control sample. Combining a QOL survey with an esophageal module makes this instrument more specific. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Esophageal reconstruction; Colon interposition; Quality of life; Long-term outcome; RAND 36
After an unfortunate intake of acids or alkalis, a scar forms and later narrows the lumen of the esophagus. These chemicals are drunk accidentally or as suicidal attempts. In cases of extreme dysphagia, physicians consider esophageal reconstruction to avoid permanent gastrostomy and to restore the ability to take nutrition by mouth. In our clinic we are using small or large intestine as a pedicle graft to maintain continuity of the digestive tract. The choice of intestine type used is based on the mesenteric vessel system, which allows us to mobilize intestinal graft of the appropriate length. Esophageal reconstruction for benign disease is performed infrequently. Consequently, little is known about the impact on patients’ postoperative symptoms and quality of life (QOL). The purpose of this study was to describe long-term overall QOL and symptoms experienced by patients who underwent esophageal reconstruction using intestinal pedicle grafts. The procedure of esophagus reconstruction begins with estimating the vascular conditions of the intestines, looking
for a long enough pedicle graft. First, we try to employ jejunum. If the jejunum’s vascular system looks poor, we consider large intestine. There is a possibility of creating the esophagus from the right colon with the vascular stalk of middle or left colic vessels placed isoperistaltically. When vascular anastomoses between the colon and ileum are developed well enough, there is another combined modality of esophageal reconstruction: use of ileum and ascending colon placed isoperistaltically with a vascular stalk of middle or right colon. Intestinal segments, which are mobilized for esophagus reconstruction, are next moved to the neck, under the sternum, to the anterior mediastinum. We suture this intestinal graft with the original esophagus on the neck, above the constricted fragment. The lower part of the original esophagus is blind-closed. The mobilized intestine in the abdominal cavity is sutured to the anterior wall of the stomach.
* Corresponding author. Tel.: ⫹48-71-370-0250; fax: ⫹48-71-341-8317. E-mail address: [email protected]
From the group of patients who underwent esophageal reconstruction for benign esophageal disease at the Depart-
Methods
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.010
K. Grabowski et al. / The American Journal of Surgery 187 (2004) 422– 426
ment of Gastrointestinal Surgery of Wroclaw Medical University in the last 45 years, 64 addresses are currently available for the study. Patients (group 1) were invited by mail to fill in a combined two-part questionnaire (RAND 36) regarding esophageal function and quality of life. The control group (group 2), as a general population sample, was created by randomized sampling of 400 individuals from among residents of Lower Silesia; percentages of sex and age were similar to the patients’ group [1,2]. The data were obtained upon request from the residents’ database of the Lower Silesia Registry Office. Sampled people were asked by mail to complete and return a quality of life survey (RAND 36) with a demographic appendix. The esophageal function and quality of life survey was assessed by a two-part mail survey. Part one, an esophageal module developed by the investigators, evaluated subjective digestive function, the act of swallowing, quantity of food and drink intake, size and frequency of daily meals, and severity of related symptoms while eating. Group 1 was additionally divided into three subgroups based on the act of swallowing: (a) fully satisfied— unlimited size and frequency of swallowing, free of choking and regurgitation; (b) good with some difficulties—small gulps with breaks, infrequent chokes and regurgitations; and (c) bad—supported act of swallowing, ie, the Valsalva maneuver or pressing on the left side of the neck was needed. Part two of the mail survery consisted of a generic QOL instrument: the RAND 36 (equivalent to the 36-Item ShortForm Health Survey), which is a self-administered health assessment tool that permits group comparisons in eight conceptual areas covering general health (health perception), daily activities (physical functioning), work (rolephysical), emotional problems (role-emotional), social activities (social functioning), nervousness/depression (mental health), pain (bodily pain), and vitality (energy/fatigue). We have used a Polish version of this survey, which was validated by Prof. M. Jarema [3]. A numeric score is computed for the answers in each of the conceptual categories. Means and standard deviations of the score were determined and compared between group 1 and group 2 matched for age and sex. Factors affecting QOL were also analyzed.
Table 1 Demographic characteristics of study groups
Age (years) Mean ⫾ SD Range Sex, female:male Martial status Single Married Widow/er Education level Low Medium High Occupational status Employed Retired/social service Residence Village Town/city Living Alone With family Economical status Fully satisfying Mildly satisfying Unsatisfying
Group 1 (patients) n ⫽ 39
Group 2 (controls/gp) n ⫽ 114
48.1 ⫾ 11.8 26–79 11:28 (72%)
50 ⫾ 13.2 20–92 33:81 (71%)
8 29 2
20 86 8
20 16 3
22 54 38
12 (31%) 27
77 (68%) 37
6 33
19 95
4 35
20 94
3 22 14
25 64 25
to unreliable responses and mental disorders reported as comorbidities. We qualified 39 patients (group 1) and 114 control subjects (group 2) for further analysis. Mean age and sex distributions were similar in both groups (Table 1). The demographic data show lower educational level and lower percentage of employment in group 1 than in group 2. There was similar distribution of marital status, residence, and living with family. We found slightly better economic status in group 2. The clinical data of group 1 (Table 2) shows that any type of intestine graft used is favorable, and the mean cause Table 2 Clinical characteristics of group 1
Statistical analysis The differences seen between the two groups were examined using the Mann-Whitney U test. Any linear association between clinical factors and QOL categories was examined by Spearman rank correlation. A P value of less than 0.05 was considered significant.
Results In all, 45 patients (73%) from group 1 and 129 subjects (32%) from group 2 responded to the surveys. We excluded 6 patients from group 1 and 15 subjects from group 2 owing
423
Group 1 (patients) n ⫽ 39 Time after reconstructive operation (years) Mean ⫾ SD Range Type of employed intestine Small intestine Large intestine Both (combined type) Causes of esophageal disease Chemical ingestion Acid Alkali Developmental disorder Comorbidities
19.5 ⫾ 13.7 0.5–43 12 11 16
18 19 2 19 (49%)
424
K. Grabowski et al. / The American Journal of Surgery 187 (2004) 422– 426 Table 4 Mean and SD of quality of life scores in both groups
Table 3 Intake of meals and drinks in group 1 patients, (n ⫽ 39) Number of patients
Speed of swallowing Unlimited Slow With breaks Meals (size) Normal Well chewed Pureed Method of supported swallowing Valsalva maneuver Pressing of left side of neck Additional gulps Followed by drinking
Meals (solid)
Drinks
10 (26%) 23 (59%) 6 (15%)
18 (46%) 15 (39%) 6 (15%)
10 (26%) 25 (64%) 4 (10%) Always Sometimes
— — — Always
— — — Sometimes
1 12
11 8
4 3
12 11
7 19
18 15
0 —
0 —
RAND 36 scales
Group 1 (patients) n ⫽ 39
Group 2 (controls) n ⫽ 114
P value
General health Physical functioning Role-physical Role-emotional Social functioning Mental health Bodily pain Vitality
46.3 (24) 72.6 (45) 49.1 (45) 53.7 (42) 62.2 (29) 59.9 (22) 59 (30) 53.6 (21)
58 (20) 83 (20) 67 (40) 67 (42) 70 (24) 63 (19) 63 (28) 55 (18)
0.008 0.019 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05
Higher score ⫽ better quality of life.
of esophageal disease was obstruction after chemical burning. Nineteen patients (49%) reported other comorbidities and disorders with no connection to the reconstructed esophagus. Food and drink intake, esophageal symptoms, swallowing As displayed in Table 3, most of the patients take meals slowly (59%) and drink with unlimited speed (46%). Eating followed by drinking, pressing of the left side of the neck, and additional gulps are frequently used supportive methods of swallowing. Well-chewed meals were preferred by 64.2% of patients. Esophageal symptoms appeared directly after the surgical treatment in 12 patients (30.8%) and more than 1 year after operation in 9 patients (23%). In our study 18 patients (46.2%) reported having an asymptomatic esophagus. In others, the most frequent esophageal symptoms were choking (severe, 10 patients; mild, 10), burping (severe, 9 patients; mild, 6), postprandial fullness (14 patients), and reflux (6 patients). Swallowing was fully satisfying for 16 patients (41%), good with some difficulties for 18 (46%), and bad for 5 (13%). Quality of life The median scores and standard deviations of all QOL areas in both groups are shown in Table 4. In general patients reported poorer mean QOL in most areas, but only 2 of 8 appeared to be statistically significant (general health and physical functioning; P ⬍0.01) by comparision with the sample from the general population. The difference in general health perception among women was not statistically significant.
When comparing patients with (n ⫽ 19) and without (n ⫽ 20) other comorbidities, we found some differences in bodily pain (P ⫽ 0.05) and mental health (P ⬍0.02) scales. Comparision of QOL of the patient subgroups showed significant differences between group (a) and group (b) as well as between groups (a) and (c) (P ⬍0.01) in 6 of 8 areas, but no significant difference between groups (b) and (c). Twelve patients (31%) reported working and 18 (46%) declared a wish to be term employees. Twenty-three patients (59%) feel psychic distress connected with the reconstructed esophagus: in 18 patients it occurs in relation to food intake; in 7 patients it is related to postoperative scarring.
Comments A better understanding of the functional outcome and quality of life of long-term survivors is needed in this new era of health care. If surgeons are to better plan preoperative counseling, surgical approach, and postoperative care, appropriate instruments to measure impact on patients’ postoperative experience of symptoms and quality of life, however limited, will become increasingly important. In end-stage esophageal disease, colon or ileum interposition is employed to recover function of the esophagus [4 –7]. In the esophagus reconstruction surgery, the stomach may also be employed. In cases of diffuse esophageal constriction after being burned, the stomach can be used only when not injured (burned). These cases should proceed with original esophagus removal. In our clinic we are doing that type of surgery only for esophageal cancer. Our own long-term experience in assessing reconstructed esophagus function, using radiological examinations and endoscopies, indicates that esophagus constructed from small intestine is functioning better than that constructed from large intestine. Esophageal reconstruction for benign disease results in functional improvement for the majority of patients, with acceptable morbidity and and low mortality rates [4,6,8 – 10]. A comparison of many postoperative functional reports is difficult because of the heterogeneity of tools used to
K. Grabowski et al. / The American Journal of Surgery 187 (2004) 422– 426
grade the functional outcome. Only a few of them use self-assessment instruments [6,11,12]. The SF-36 Health Survey (RAND 36) is a widely used instrument for measuring overall QOL of patients with chronic diseases and cancer, and also after esophageal operations [11,13–16]. The convenient form of the survey, good psychometric parameters, and validity in an elderly population are advantages that allowed comparison between investigated groups [15,17–20]. In the present study, we combined a QOL survey with a questionnaire aimed at esophageal function. In our study more than half (54%) of surveyed patients are symptomatic. In the majority of them (57% of symptomatic patients), esophageal symptoms appeared directly after the surgical treatment. More than 51% complained of severe or mild choking, 38% had severe or mild burp, and 36% had postprandial fullness. Others [4,9] have also reported these findings with similar distribution of symptoms. A few patients (n ⫽ 6; 15%) complained of gastric reflux; we explain this as a result of the antireflux surgical methods used during the initial reconstruction. [21,22]. Swallowing was reported as bad only in 5 patients (13%), which is evidence for good function and efficiency of the replaced esophagus. Similar data were previously reported as well [6,8 –10,12,23,24]. The long-term health-related QOL of patients was comparable (statistically nonsignificant differences) with that of the general population sample except in two areas: general health perception and physical functioning. The health-related QOL varied among patient subgroups depending on dysphagia during the act of swallowing. We found significantly better QOL among patients with fully satisfying and good swallowing. This correlation has already been reported [11,24] for patients treated for benign disease of the esophagus, but not for patients with cancer of the esophagus [25]. The subgroup of patients whose health status is not additionally impaired by comorbidities seems to be quite close to the general population in health-related QOL. The presence of comorbidities impairs QOL, especially in the areas of emotional well-being and pain. In our study a correlation between QOL scales and type of intestinal pedicle grafts as well as time after esophageal reconstruction does not exist [11,22]. Of the demographic factors, only two seemed to have influence on some of QOL areas: males reported lower scores in physical functioning and bodily pain; and better economic status was correlated with higher scores in the mental health area (rs 0.3; P ⬍0.05). However, Young et al [11] in a study of 81 patients with reconstructed esophagus did not find any demographic factors to have influence on general QOL. On the other hand, some studies of QOL in patients with chronic diseases have reported an influence of sex, age, occupation, and other demographic factors on general QOL [2,13,26]. The limitation to our study is a small sample size, which constitutes only a fraction of the patients who underwent
425
reconstruction for benign disease during the last 45 years in our clinic. There is also a possibility that differences in many or most of the QOL categories would be significant given larger numbers of patients. We conclude that esophageal reconstruction using intestinal pedicle grafts affects the appearance of symptoms such as choking, burping, and postprandial fullness, which are not uncommon. Long-term quality of life as assessed by the patients themselves is adversely affected in two areas and similarly in six of eight conceptual areas when compared with the general population sample. We observed that functional outcome and QOL scores are not affected by age, type of intestinal pedicle graft, or time after esophageal reconstruction; and are slightly affected by sex and economic status. Combining an overall QOL survey with a module aimed at esophageal function makes this instrument more specific and useful.
References [1] Craig JR, Metze LP. Methods of Psychological Research. Monterey, CA: Brooks/Cole Publishing, 1986. [2] Aaronson NK, Muller M, Cohen PD, et al. Translation, validation, and norming of the Dutch language version of SF-36 health survey in community and chronic disease populations. J Clin Epidemiol 1998; 11:1055. [3] Jarema M, Konieczyn´ ska Z, Glo´ wczak M, et al. The evaluation of subjective quality of life in patients with schizophrenia or depression. Psychiatr Pol 1996;3(suppl 3):119. [4] Watson TJ, De Meester TR, Kauer WK, et al. Esophageal replacement for end-stage benign esophageal disease. J Thorac Cardiovasc Surg 1998;115:1241. [5] Curet-Scott MJ, Ferguson MK, Little AG, et al. Colon interposition for benign esophageal disease. Surgery 1987;102:568. [6] Blaszczuk J, Grabowski K, Wierzbicki J, et al. Esophageal substitute corrective operations [in Polish]. Wiad Lek 2000;53:142–5. [7] Bernat M, Bader O, Milnerowicz S, et al. Colon or ileum for reconstruction of the total esophagus with reference to vascularization [in German]. Zentralbl Chir 1985;110:1297–303. [8] Young MM, Deschamps C, Trastek VF, et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651–5. [9] Orringer MB, Marshall B, Stirling MC, et al. Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;105:265–77. [10] Bernat M, Milnerowicz S. Surgical reconstruction of oesophagus. Mater Med Pol 1992;24:163. [11] Young MM, Deschamps C, Allen MS, et al. Esophageal reconstruction for benign disease: self-assessment of functional outcome and quality of life. Ann Thorac Surg 2000;70:1799 – 802. [12] Buntain WL, Payne WS, Lynn HB. Esophageal reconstruction for benign disease: a long-term appraisal. Am Surg 1980;46:67. [13] Ware JE, Gandek B, for the IQOLA Project. Overview of the SF-36 health survey and the International Quality of Life Assessment (IQOLA) project. J Clin Epidemiol 1998;51:903. [14] Fernando HC, Schauer PR, Rosenblatt M, et al. Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal reflux disease. J Am Coll Surg 2002;194:23. [15] Higgins IJ, Carr AJ. How can quality of life measures be used in the clinical settings? BMJ 2001;322:1297.
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[16] Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally invasive esophagomyotomy. Ann Thorac Surg 2001;72:1909 – 12. [17] Hays RD, Sherbourne CD, Mazel RM. The RAND 36-item health survey 1.0. Health Econ 1993;2:217. [18] Hornbrook MC, Goodman MJ. Assessing relative health plan risk with the RAND-36 health survey. Inquiry 1995;32:56. [19] Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med 2001;33:350. [20] Lyons RA, Pery HM, Littlepage BNC. Evidence for the validity of the short form 36 questionnaire in an elderly population. Age Ageing 1994;23:182. [21] Milnerowicz S, Grabowski K, Knast W, Rabczynski J. Surgical methods of protecting grafts from the colon against gastric reflux [in Polish]. Wiad Lek 1997;50(suppl 1):326 –31.
[22] Milnerowicz S, Grabowski K, Strutynska-Karpinska M, Knast W. Gastroesophageal reflux after reconstruction of the esophagus with colon interposition [in Polish]. Wiad Lek 1997;50(suppl 1):322–5. [23] Kirby JD. Quality of life after oesophagectomy: the patient perspective. Dis Esophagus 1999;12:168. [24] Grabowski K, Moron´ M, Ciesielska A. An act of swallowing in patients with intestinal pedicle grafts as an oesophagus [in Polish]. In: Wybrane Zagadnienia z Chirurgii. Warsaw: Fundacja Polski Przeglad Chirurgiczny, 1999. [25] Blazeby JM, Williams MH, Brookes ST, et al. Quality of life measurement in patients with oesophageal cancer. Gut 1995;37:505– 8. [26] Kusztal M, Nowak K, Procelewska-Magott M, et al. Evaluation of health-related quality of life in dialysis patients using SF-36. Personal experience [in Polish]. Pol Merk Lek 2003:14(80):113–7.
Scientific paper
Long-term quality of life and symptoms of patients who underwent esophageal reconstruction employing intestinal pedicle grafts Krzysztof Grabowski, M.D., Ph.D.a, Mariusz Kusztal, M.D.b,* b
a Department of Gastrointestinal Surgery, Wroclaw Medical University, Wroclaw, Poland Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, ul. Traugutta 57/59, 50-417 Wroclaw, Poland
Manuscript received October 7, 2002; revised manuscript May 18, 2003
Abstract Background: This study was conducted to assess the long-term quality of life (QOL) and symptoms experienced by patients who underwent esophageal reconstruction. Methods: We invited by mail 64 patients (group 1) and 400 subjects from the general population (group 2) to complete a two-part questionnaire regarding esophageal function and QOL (RAND 36). Results: In all 39 group 1 and 114 group 2 subjects qualified for the final analysis. In the majority esophageal symptoms appeared directly after the operation. Symptoms of problems were choking (51%), burp (38%), and postprandial fullness (36%). Nineteen patients (49%) reported other comorbidities. Group 1 reported poorer QOL (P ⬍0.01) in 2 of 8 QOL areas by comparision with group 2. There were no correlations between QOL scales and type of intestinal pedicle grafts or time after esophageal reconstruction. Conclusions: Long-term QOL assessed by the patients themselves in general seems to be similar to that of the control sample. Combining a QOL survey with an esophageal module makes this instrument more specific. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Esophageal reconstruction; Colon interposition; Quality of life; Long-term outcome; RAND 36
After an unfortunate intake of acids or alkalis, a scar forms and later narrows the lumen of the esophagus. These chemicals are drunk accidentally or as suicidal attempts. In cases of extreme dysphagia, physicians consider esophageal reconstruction to avoid permanent gastrostomy and to restore the ability to take nutrition by mouth. In our clinic we are using small or large intestine as a pedicle graft to maintain continuity of the digestive tract. The choice of intestine type used is based on the mesenteric vessel system, which allows us to mobilize intestinal graft of the appropriate length. Esophageal reconstruction for benign disease is performed infrequently. Consequently, little is known about the impact on patients’ postoperative symptoms and quality of life (QOL). The purpose of this study was to describe long-term overall QOL and symptoms experienced by patients who underwent esophageal reconstruction using intestinal pedicle grafts. The procedure of esophagus reconstruction begins with estimating the vascular conditions of the intestines, looking
for a long enough pedicle graft. First, we try to employ jejunum. If the jejunum’s vascular system looks poor, we consider large intestine. There is a possibility of creating the esophagus from the right colon with the vascular stalk of middle or left colic vessels placed isoperistaltically. When vascular anastomoses between the colon and ileum are developed well enough, there is another combined modality of esophageal reconstruction: use of ileum and ascending colon placed isoperistaltically with a vascular stalk of middle or right colon. Intestinal segments, which are mobilized for esophagus reconstruction, are next moved to the neck, under the sternum, to the anterior mediastinum. We suture this intestinal graft with the original esophagus on the neck, above the constricted fragment. The lower part of the original esophagus is blind-closed. The mobilized intestine in the abdominal cavity is sutured to the anterior wall of the stomach.
* Corresponding author. Tel.: ⫹48-71-370-0250; fax: ⫹48-71-341-8317. E-mail address: [email protected]
From the group of patients who underwent esophageal reconstruction for benign esophageal disease at the Depart-
Methods
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.010
K. Grabowski et al. / The American Journal of Surgery 187 (2004) 422– 426
ment of Gastrointestinal Surgery of Wroclaw Medical University in the last 45 years, 64 addresses are currently available for the study. Patients (group 1) were invited by mail to fill in a combined two-part questionnaire (RAND 36) regarding esophageal function and quality of life. The control group (group 2), as a general population sample, was created by randomized sampling of 400 individuals from among residents of Lower Silesia; percentages of sex and age were similar to the patients’ group [1,2]. The data were obtained upon request from the residents’ database of the Lower Silesia Registry Office. Sampled people were asked by mail to complete and return a quality of life survey (RAND 36) with a demographic appendix. The esophageal function and quality of life survey was assessed by a two-part mail survey. Part one, an esophageal module developed by the investigators, evaluated subjective digestive function, the act of swallowing, quantity of food and drink intake, size and frequency of daily meals, and severity of related symptoms while eating. Group 1 was additionally divided into three subgroups based on the act of swallowing: (a) fully satisfied— unlimited size and frequency of swallowing, free of choking and regurgitation; (b) good with some difficulties—small gulps with breaks, infrequent chokes and regurgitations; and (c) bad—supported act of swallowing, ie, the Valsalva maneuver or pressing on the left side of the neck was needed. Part two of the mail survery consisted of a generic QOL instrument: the RAND 36 (equivalent to the 36-Item ShortForm Health Survey), which is a self-administered health assessment tool that permits group comparisons in eight conceptual areas covering general health (health perception), daily activities (physical functioning), work (rolephysical), emotional problems (role-emotional), social activities (social functioning), nervousness/depression (mental health), pain (bodily pain), and vitality (energy/fatigue). We have used a Polish version of this survey, which was validated by Prof. M. Jarema [3]. A numeric score is computed for the answers in each of the conceptual categories. Means and standard deviations of the score were determined and compared between group 1 and group 2 matched for age and sex. Factors affecting QOL were also analyzed.
Table 1 Demographic characteristics of study groups
Age (years) Mean ⫾ SD Range Sex, female:male Martial status Single Married Widow/er Education level Low Medium High Occupational status Employed Retired/social service Residence Village Town/city Living Alone With family Economical status Fully satisfying Mildly satisfying Unsatisfying
Group 1 (patients) n ⫽ 39
Group 2 (controls/gp) n ⫽ 114
48.1 ⫾ 11.8 26–79 11:28 (72%)
50 ⫾ 13.2 20–92 33:81 (71%)
8 29 2
20 86 8
20 16 3
22 54 38
12 (31%) 27
77 (68%) 37
6 33
19 95
4 35
20 94
3 22 14
25 64 25
to unreliable responses and mental disorders reported as comorbidities. We qualified 39 patients (group 1) and 114 control subjects (group 2) for further analysis. Mean age and sex distributions were similar in both groups (Table 1). The demographic data show lower educational level and lower percentage of employment in group 1 than in group 2. There was similar distribution of marital status, residence, and living with family. We found slightly better economic status in group 2. The clinical data of group 1 (Table 2) shows that any type of intestine graft used is favorable, and the mean cause Table 2 Clinical characteristics of group 1
Statistical analysis The differences seen between the two groups were examined using the Mann-Whitney U test. Any linear association between clinical factors and QOL categories was examined by Spearman rank correlation. A P value of less than 0.05 was considered significant.
Results In all, 45 patients (73%) from group 1 and 129 subjects (32%) from group 2 responded to the surveys. We excluded 6 patients from group 1 and 15 subjects from group 2 owing
423
Group 1 (patients) n ⫽ 39 Time after reconstructive operation (years) Mean ⫾ SD Range Type of employed intestine Small intestine Large intestine Both (combined type) Causes of esophageal disease Chemical ingestion Acid Alkali Developmental disorder Comorbidities
19.5 ⫾ 13.7 0.5–43 12 11 16
18 19 2 19 (49%)
424
K. Grabowski et al. / The American Journal of Surgery 187 (2004) 422– 426 Table 4 Mean and SD of quality of life scores in both groups
Table 3 Intake of meals and drinks in group 1 patients, (n ⫽ 39) Number of patients
Speed of swallowing Unlimited Slow With breaks Meals (size) Normal Well chewed Pureed Method of supported swallowing Valsalva maneuver Pressing of left side of neck Additional gulps Followed by drinking
Meals (solid)
Drinks
10 (26%) 23 (59%) 6 (15%)
18 (46%) 15 (39%) 6 (15%)
10 (26%) 25 (64%) 4 (10%) Always Sometimes
— — — Always
— — — Sometimes
1 12
11 8
4 3
12 11
7 19
18 15
0 —
0 —
RAND 36 scales
Group 1 (patients) n ⫽ 39
Group 2 (controls) n ⫽ 114
P value
General health Physical functioning Role-physical Role-emotional Social functioning Mental health Bodily pain Vitality
46.3 (24) 72.6 (45) 49.1 (45) 53.7 (42) 62.2 (29) 59.9 (22) 59 (30) 53.6 (21)
58 (20) 83 (20) 67 (40) 67 (42) 70 (24) 63 (19) 63 (28) 55 (18)
0.008 0.019 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05
Higher score ⫽ better quality of life.
of esophageal disease was obstruction after chemical burning. Nineteen patients (49%) reported other comorbidities and disorders with no connection to the reconstructed esophagus. Food and drink intake, esophageal symptoms, swallowing As displayed in Table 3, most of the patients take meals slowly (59%) and drink with unlimited speed (46%). Eating followed by drinking, pressing of the left side of the neck, and additional gulps are frequently used supportive methods of swallowing. Well-chewed meals were preferred by 64.2% of patients. Esophageal symptoms appeared directly after the surgical treatment in 12 patients (30.8%) and more than 1 year after operation in 9 patients (23%). In our study 18 patients (46.2%) reported having an asymptomatic esophagus. In others, the most frequent esophageal symptoms were choking (severe, 10 patients; mild, 10), burping (severe, 9 patients; mild, 6), postprandial fullness (14 patients), and reflux (6 patients). Swallowing was fully satisfying for 16 patients (41%), good with some difficulties for 18 (46%), and bad for 5 (13%). Quality of life The median scores and standard deviations of all QOL areas in both groups are shown in Table 4. In general patients reported poorer mean QOL in most areas, but only 2 of 8 appeared to be statistically significant (general health and physical functioning; P ⬍0.01) by comparision with the sample from the general population. The difference in general health perception among women was not statistically significant.
When comparing patients with (n ⫽ 19) and without (n ⫽ 20) other comorbidities, we found some differences in bodily pain (P ⫽ 0.05) and mental health (P ⬍0.02) scales. Comparision of QOL of the patient subgroups showed significant differences between group (a) and group (b) as well as between groups (a) and (c) (P ⬍0.01) in 6 of 8 areas, but no significant difference between groups (b) and (c). Twelve patients (31%) reported working and 18 (46%) declared a wish to be term employees. Twenty-three patients (59%) feel psychic distress connected with the reconstructed esophagus: in 18 patients it occurs in relation to food intake; in 7 patients it is related to postoperative scarring.
Comments A better understanding of the functional outcome and quality of life of long-term survivors is needed in this new era of health care. If surgeons are to better plan preoperative counseling, surgical approach, and postoperative care, appropriate instruments to measure impact on patients’ postoperative experience of symptoms and quality of life, however limited, will become increasingly important. In end-stage esophageal disease, colon or ileum interposition is employed to recover function of the esophagus [4 –7]. In the esophagus reconstruction surgery, the stomach may also be employed. In cases of diffuse esophageal constriction after being burned, the stomach can be used only when not injured (burned). These cases should proceed with original esophagus removal. In our clinic we are doing that type of surgery only for esophageal cancer. Our own long-term experience in assessing reconstructed esophagus function, using radiological examinations and endoscopies, indicates that esophagus constructed from small intestine is functioning better than that constructed from large intestine. Esophageal reconstruction for benign disease results in functional improvement for the majority of patients, with acceptable morbidity and and low mortality rates [4,6,8 – 10]. A comparison of many postoperative functional reports is difficult because of the heterogeneity of tools used to
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grade the functional outcome. Only a few of them use self-assessment instruments [6,11,12]. The SF-36 Health Survey (RAND 36) is a widely used instrument for measuring overall QOL of patients with chronic diseases and cancer, and also after esophageal operations [11,13–16]. The convenient form of the survey, good psychometric parameters, and validity in an elderly population are advantages that allowed comparison between investigated groups [15,17–20]. In the present study, we combined a QOL survey with a questionnaire aimed at esophageal function. In our study more than half (54%) of surveyed patients are symptomatic. In the majority of them (57% of symptomatic patients), esophageal symptoms appeared directly after the surgical treatment. More than 51% complained of severe or mild choking, 38% had severe or mild burp, and 36% had postprandial fullness. Others [4,9] have also reported these findings with similar distribution of symptoms. A few patients (n ⫽ 6; 15%) complained of gastric reflux; we explain this as a result of the antireflux surgical methods used during the initial reconstruction. [21,22]. Swallowing was reported as bad only in 5 patients (13%), which is evidence for good function and efficiency of the replaced esophagus. Similar data were previously reported as well [6,8 –10,12,23,24]. The long-term health-related QOL of patients was comparable (statistically nonsignificant differences) with that of the general population sample except in two areas: general health perception and physical functioning. The health-related QOL varied among patient subgroups depending on dysphagia during the act of swallowing. We found significantly better QOL among patients with fully satisfying and good swallowing. This correlation has already been reported [11,24] for patients treated for benign disease of the esophagus, but not for patients with cancer of the esophagus [25]. The subgroup of patients whose health status is not additionally impaired by comorbidities seems to be quite close to the general population in health-related QOL. The presence of comorbidities impairs QOL, especially in the areas of emotional well-being and pain. In our study a correlation between QOL scales and type of intestinal pedicle grafts as well as time after esophageal reconstruction does not exist [11,22]. Of the demographic factors, only two seemed to have influence on some of QOL areas: males reported lower scores in physical functioning and bodily pain; and better economic status was correlated with higher scores in the mental health area (rs 0.3; P ⬍0.05). However, Young et al [11] in a study of 81 patients with reconstructed esophagus did not find any demographic factors to have influence on general QOL. On the other hand, some studies of QOL in patients with chronic diseases have reported an influence of sex, age, occupation, and other demographic factors on general QOL [2,13,26]. The limitation to our study is a small sample size, which constitutes only a fraction of the patients who underwent
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reconstruction for benign disease during the last 45 years in our clinic. There is also a possibility that differences in many or most of the QOL categories would be significant given larger numbers of patients. We conclude that esophageal reconstruction using intestinal pedicle grafts affects the appearance of symptoms such as choking, burping, and postprandial fullness, which are not uncommon. Long-term quality of life as assessed by the patients themselves is adversely affected in two areas and similarly in six of eight conceptual areas when compared with the general population sample. We observed that functional outcome and QOL scores are not affected by age, type of intestinal pedicle graft, or time after esophageal reconstruction; and are slightly affected by sex and economic status. Combining an overall QOL survey with a module aimed at esophageal function makes this instrument more specific and useful.
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