| [Backgrounds]The remnant stomach after subtotal gastrectomy was considered as a precancerous disease. The occurrence of gastric stump carcinogenesis is equivalent to the primary gastric cancer. It is a complex process, influenced by many factors, and also has its particularity. Helicobacter pylori(H. pylori) infection is one of the risk factors of gastric stump carcinogenesis in early postoperative patients with gastric carcinoma. It is associated with the different stages of gastric stump carcinoma. H. pylori infection causes different histological changes of gastric cancer precursor lesion in the gastric stump such as chronic gastritis and atrophy of the gastric mucosa,intestinal metaplasia,dysplasia and adenoma.Accurate diagnosis and eradication of H. pylori is essential in the patients with remnant stomach. It is now the gold standard internationally recognized for the detection of H. pylori and anti H. pylori therapeutic drug monitoring. Due to the influence of bacterial load reduction,emptying of gastric stump for13C-urea too fast and other factors after subtotal gastrectomy,the value of13C-UBT used in gastric remnant populations remain controversial.So we need to find a suitable method for detecting H. pylori in patients with gastric stump in clinical practice. H. pylori eradication therapy were as important to the remnant stomach after distal gastrectomy as to the unoperated stomach.The protocol for H. pylori eradication in the remnant stomach, however,has not been established.Effect of the conventional scheme in eradication in the patients with remnant stomach of H. pylori infection is not consistent. Consequently,it is particularly important to explore and formulate suitable regimen for H. pylori eradication therapy in gastric remnant.With the improvement of medical technology and clinical research,early diagnosis of patients with gastric cancer and radical operation are increasing.On the one hand the patients with gastric stump get rid of the puzzles suffering from cancer, on the other hand they will face all sorts of loss of body function and mental disorders,leading to a decline in health related quality of life.If they are confronted with gastric stump carcinogenesis again, they will battered in physical and mental. Although the operation treatment can prolong the survival period of the patients, a variety of psychological and social problems suffer from the disease will continue to influence physical and mental health of these patients. The incidence of gastric stump cancer is still increasing.There are less research in the evaluation of HRQoL (Health-related quality of life) of patients with gastric stump cancer and its influencing factors in out country.[Aims]1. To analysis the relationship between persistence of H. pylori and remnant mucosal lesions following partial gastrectomy.2. To investigate the diagnostic efficacy of13C-urea breath test for diagnosis of H.pylor infection in patients after partial gastrectomy.3. To evaluation the efficacy and safety of triple therapy combined with posture change after taking medicine for H. pylori eradication in remnant stomach, and exploration the suitable method of H. pylori eradication.4. To investigate the health-related quality of life and its influencing factors in patients with gastric remnant cancer.[Methods]1. The141patients with gastric stump after partial gastrectomy for benign peptic ulcer (group A, n=58) and early gastric cancer (group B, n=83) were included in this prospective study.All patients underwent upper digestive endoscopy and biopsy specimens of the gastric stump were tested for the occurrence of H. pylori infection and for the presence of remnant mucosal lesions.2. A total of94gastric remnant patients (gastric remnant group) and100non-gastric remnant patients (control group) received13C-UBT. Each patient in gastric remnant group completed a modified13C-UBT protocol with using mouthwash, the body in a horizontal position on the left side within thirty minutes after ingestion. According to the course of the disease,the gastric remnant group were divided into group1(29cases,≤5years), group2(33cases,6to10years) and group3(32cases,>10years).Before surgery, the diagnosis of H. pylori infection was according to13C-UBT and gastric mucosa tissue staining.After surgery,the diagnosis was according to gastric mucosa tissue staining.The applying value of13C-UBT in gastric remnant patients was evaluated.The consistency of results between13C-UBT and gastric mucosa tissue staining were evaluated by the Kappa test.3. A total of54H. pylori infected patients with remnant stomach and30H. pylori infected patients without remnant stomach were enrolled. The patients with remnant stomach were randomly assigned into remnant stomach group Ⅰ and group Ⅱ, the patients without remnant stomach were assigned into control group. Patients in remnant stomach group Ⅰ were given esomeprazole20mg bid+amoxicillin1000mg bid+furazolidone100mg bid (EAF regimen) for10days. Patients in remnant stomach group Ⅱ were given EAF regimen and kept left lateral position for30min for10days. Patients in control group were given regimen for10days. Three months after the course of treatment, rapid urease test (RUT) and gastric mucosal tissue sections staining were examined to assess H. pylori eradication rate. Gastroscopy was applied before and3months after the treatment, visual analogue scales were used for grading the histopathologic features.4. A total of130patients received gastrectomy (Billroth I or II type) more than10years ago because of early gastric cancer.According to the gastric remnant canceration after the surgery,patients were divided into GRC group (80cases) and gastric remnant group (50cases). Both the patients of these two groups and the patients in control group accepted questionnaires of cancer patients quality of life questionnaire (QLQ)-C30and gastric cancer specific questionnaire QLQ-STO22, the HRQoL were evaluated. All data was analyzed using SPSS16.0.[Results]1. The prevalence of inflammation (P>0.05),activity (P<0.05) and H. pylori infection (P<0.05) in the group A was higher than that in the group B. All H. pylori-positive cases in the2groups showed a higher prevalence of chronic atrophic gastritis,intestinal metaplasia,gastric cancer precursor lesion and activity (P<0.05).Whereas H. pylori-negative cases in the2groups showed a prevalence of chronic nonatrophic gastritis (P<0.05).There was a negative correlation between the grade of gastric mucosal lesions and H. pylori positivity in the2groups (P>0.05).H. pylori infection were significantly associated with the gastric cancer precursor lesions in the2groups (P<0.05) 2. In gastric remnant group with a modified13C-UBT protocol,the H. pylori infection rate after surgery (37.2%) was obviously lower than that before operation (79.8%;χ2=35.058, P<0.01) and that of control group (77.0%). After surgery,the H. pylori infection rate of patients with Billroth Ⅱ gastrectomy (24.2%) was lower than that of patients with Billroth Ⅰ gastrectomy (47.2%; χ2=5.133, P=0.023). Before surgery,the H. pylori infection rate of gastric remnant subgroups were similar (P>0.05). With the extension of the postoperative course, the H. pylori infection rate gradually decreased in gastric remnant subgroups (group1:58.6%, group2:36.4%, group3:18.8%;χ2=7.839, P=0.021).Setting the cut-off point at2.0%o in the gastric remnant group and3.5%o in the control group, the accuracy rate of diagnosis was the highest (92.6%and96.0%). There was a good consistency between the results of13C-UBT and gastric mucosa tissue staining (Kappa=0.84,P<0.01)3. H. pylori eradication rate in remnant stomach group Ⅰ was significantly lower than that in control group by intention-to-treat (ITT) and per-protocol (PP) analysis (P<0.05); The eradiction rate in remnant stomach group Ⅱ was higher than that in remnant stomach group I by ITT and PP analysis, but there is no statistically significant difference (P>0.05). No significant difference in eradication rate by ITT and PP analysis was found between remnant stomach group Ⅱ and control group (P>0.05). The eradication rate was not differ with reconstruction method (Billroth Ⅰ or Billroth Ⅱ) by ITT and PP analysis (P>0.05).Afte the treatment, inflammation and activity scores were significant decreased in each group (P<0.05), but no significant difference were seen in glandular atrophy and intestinal metaplasia scores (P>0.05). The incidences of adverse effect in the three groups has no statistically significant difference (P>0.05), and no serious adverse effects occurred during the course.4. All the research objectives finished the questionnaires survey.Totally230qualified questionnaires were obtained,and the response rate was100%. Each questionnaire was completed within8.4±2.4min.The interclass correlation between test and retest was high and Pearson correlation coefficients were0.77～0.94and0.77～0.91.All scales of the QLQ-C30and QLQ-STO22exhibited high internal consistency:Cronbach’s alpha coefficients were0.77～0.90and0.87～0.90for each scale.Applied principal constituent to analysis construction validity to retrieval two and one main factors, which could account for57.6%and 61.4%of tatal variance, respectively.The factor loads were0.43～0.82and0.55～0.90. Compared with health control group, the scores of GRC group were lower,which included quality of life evaluation,physical function,role function,emotional function,cognitive function and social function,and the differences were statistically significant (t=-6.678,-7.111,-10.605,-5.748,-4.765and-21.170, all P<0.01).The scores of fatigue, pain,diarrhea,nausea and vomiting,loss of appetite,economic difficulties,dysphagia,abdominal pain,reflux symptoms,diet restricted, anxiety, physical appearance and hair loss were higher,and the differences were significant (t=6.925,4.218,4.728and Z=-5.236,-7.89,-7.698,-10.058,-3.612,-6.914,-9.711,9.940,-7.987and-4.966, all P<0.01).Compared with gastric remnant group, the scores of GRC group were lower,which included quality of life evaluation, physical function,role function,emotional function,cognitive function and social function,and the differences were statistically significant(t=-5.861,-5.821,-7.077,-7.999,-2.808and-5.710, all P<0.01). However the scores of fatigue,pain, diarrhea,nausea and vomiting,loss of appetite,economic difficulties, dysphagia, abdominal pain,reflux symptoms,diet restricted,anxiety, physical appearance and hair loss were higher,and the differences were significant (t=9.363,6.842and Z=-2.654,-6.256,-3.266,-4.132,-2.854,-7.996,-4.258and-2.005, all P<0.01).Compared with health control group, the score of social function of gastric remnant group was lower and the difference was significant (t=-9.820, P<0.01);the scores of diarrhea,nausea and vomiting,economic difficulties, dysphagia,reflux symptoms,diet restricted,physical appearance and hair loss were higher,the differences were statistical significant (t=3.020and Z=-1.981,-3.775,-6.505,-6.098,-8.032,-3.369and-3.147, all P<0.05);the symptom scores of fatigue and pain were lower, the differences were significant (t=-2.890and-2.439, all P<0.05).HRQoL of patients was positively correlated with education degree,marital status,family income and the disease course of gastric remnant.[Conclusion]1. H. pylori infection were associated with the remnant mucosal lesions following partial gastrectomy.2. Mouthwash and a cutoff of2.0per thousand were found to be optimal for the test in the remnant stomach after surgery, with the body position horizontal on the left side within thirty minutes after ingestion. Being a noninvasive diagnostic tool, the13C-UBT was a convenient, safety and reliable tool with the same accuracy rate as other routine tests provided that the conditions for performing the test were proper and the evaluation standard for detection of H. pylori was suitable in the remnant stomach after gastrectomy.3. Triple therapy (EAF regimen) combined with posture change(keep left lateral position for30min) after taking medicine is a safe and effective treatment for eradication of H. pylori in remnant stomach.4. The EORTC QLQ-C30is therefore recommended as a reliable and valid tool to use with the QLQ-STO22to assess HRQoL in GRC patients. HRQoL of GRC patients decreased to certain degree.Education degree,marital status,family income and the disease course of gastric remnant were the influential factors of HRQoL in GRC patients. |
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