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Surgical Influence: How does major abdominal surgery influence appetite?
This supplemental digital content describes in detail the influence of different surgical procedures on postoperative appetite.
Esophageal Surgery
Patients reported appetite reduction or complete absence of appetite for weeks after after esophageal resection1. Indeed, thoracoabdominal esophagectomy causes clinically significant appetite loss three and six months 2, as well as one 3 and two years after surgery 4, but appetite loss may improve after the first six months 5. Appetite loss is also associated with severe weight loss 6 and may contribute to the development of depression 7. Furthermore, appetite loss is an independent predictor of cancer-specific survival 8. Nevertheless, appetite loss after surgery for esophageal cancer may be less than after surgery for gastric cancer; 9 recovery of initial appetite loss after esophageal resection is not influenced by preoperative treatment with chemotherapy or radiochemotherapy 10. Regarding surgical approach, McKeown versus Ivor- Lewis esophagectomy resulted in similar appetite loss two to three years after operation 11. A modified merendino resection, when compared to Ivor-Lewis esophagectomy, resulted in greater appetite loss one year, but not anymore two years after resection for early Barett’s cancer 12. In patients with previous gastrectomy undergoing esophagectomy, gastric remnant reconstruction yielded the best results regarding appetite when compared to reconstruction with jejunum or colon 13. Robot-assisted transmediastinal esophagectomy resulted in less appetite loss than transthoracic esophagectomy with thoracotomy in patients more than 3 months after the operation or the last administration of chemotherapy 14.
Lagergren and colleagues have repeatedly published on appetite loss after esophageal surgery based on a nationwide, population-based study in Sweden. Here, appetite loss six months after surgery was worse among younger patients 15 and correlated with increased weight loss at six months 16 and five years after surgery 17. Appetite loss six months after
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surgery was a negative predictor of long-term survival 18, remained a problem for three years after surgery for two-thirds of patients, and was worse than in the general population for all patients 19. Other studies found that, as late as five to ten years after surgery, appetite loss was a clinically relevant problem with further potential to worsen 20, and even more so among patients with general eating difficulties 21. Furthermore, patients whose comorbidities increased over time after surgery reported more severe appetite loss three to five years after surgery 22. Regarding technical aspects, appetite loss three years after surgery was not influenced by a handsewn versus stapled anastomosis or by a transthoracic versus transhiatal approach 23. Also, a larger extent of lymphadenectomy measured by the number of lymph nodes removed did not impair appetite, but may even be associated with less appetite loss 24.
Gastric Surgery
In this systematic review, gastric surgery represented the largest number of studies reporting unintentional appetite loss (n=48).
As early as 1967, Adams found lack of appetite and absence of hunger as important reasons for suboptimal dietary intake in a series of 20 patients who survived at least one year after total gastrectomy for benign or malign indications 25. One year later, Scott et al. reported the evaluation of the Hunt-Lawrence jejunal food pouch combined with Roux-en-Y esophago- jejunostomy in 22 patients. Among eight long-term survivors (three to five years), they found appetite to be “good” (n=7) or “fair” (n=1), which they considered similar to the preoperative situation 26.
Since these early reports on postoperative appetite loss, randomized, controlled data on the subject have been sparse. Laparoscopic-assisted distal gastrectomy was reported to result in less appetite loss compared to open distal gastrectomy at 7 and 30 days, but appetite returned to preoperative levels in both groups 90 days after the operation 27. Kim et al. reported less appetite loss in vagal nerve preserving distal gastrectomy than in conventional distal gastrectomy 3 and 12 months after surgery 28. Non-randomized trials have also identified the positive effects of vagal nerve preservation on appetite loss 29,30. However, conflicting data
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from a non-randomized study show no difference and a healthy appetite in all patients five years after pylorus-preserving gastrectomy 31. Syn et al. performed a meta-analysis of 17 randomized trials and 8 observational studies involving 1,621 patients comparing reconstruction with or without a pouch after total gastrectomy for cancer. They did not report on appetite specifically, but did address a much broader concept of “food intake disturbance,”
which appeared to benefit from pouch formation 32.
Apart from that, numerous non-randomized studies or cohort studies have investigated the effects of different surgical techniques on appetite loss after gastrectomy. Appetite loss is a common problem after gastric surgery 33, effecting 20% 34 to 78% of patients 35, when compared to healthy controls 36. Patients can also have normal postprandial hunger and prospective consumption sensations following surgery, but an earlier and increased feeling of fullness 37. Only a few studies report no loss of appetite, but a significant decrease in body weight 38.
Wu et al. found no difference in postoperative appetite among D2, D3, and D4 lymphadenectomy patients, between subtotal gastrectomy with Billroth I or Billroth II reconstruction or total gastrectomy with Roux-en-Y anastomosis, or between male and female patients. However, appetite was worse for patients over 65 when compared to younger patients. While appetite improved in general one year after surgery and stabilized after that, it was only considered “good” by two-thirds of patients 39. Similarly, Scurtu et al. found no significant difference in appetite between different types of anastomosis (Roux-en-Y end-to- end vs. end-to-side, manual vs. stapler) or stapler diameter (<28mm or >28mm). Three months after surgery, however, loss of appetite was worse if anastomotic fistula had occurred
40. Lee et al. reported that laparoscopy-assisted distal gastrectomy with jejunal pouch achieved better results regarding appetite and significantly less weight loss than a procedure with Billroth-II-reconstruction four years after the operation 41. Huang et al. found that laparoscopy- assisted pylorus-preserving gastrectomy resulted in less appetite loss than laparoscopy- assisted distal gastrectomy with Billroth-I-reconstruction in patients with middle-third early gastric cancers two years after surgery 42. Both laparoscopic and open distal gastrectomy
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(both with Billroth-I-reconstruction) resulted in similar appetite loss three years after the operation 43.
Some studies reported less appetite loss when, instead of total gastrectomy, a subtotal gastrectomy 44,45 or endoscopic submucosal dissection 46 (with the later potentially resulting in a higher fear of cancer recurrence) was performed 47. Formation of a jejunal pouch may lead to better appetite after surgery 35. Tomaszewski et al. found worse appetite loss in a cohort of patients with esophageal or gastric cancer if patients were >60 years old (vs. <60 years), retired (vs. working), received palliative treatment (vs. curative), or had a tumor located in the stomach (vs. the esophagus). Appetite loss was also one of the main health-related quality of life issues, along with fatigue and insomnia 9.
The negative predictive value of appetite loss on quality of life 48 and a correlation between appetite loss and drop in body-mass-index 49,50 or self-assessed malnutrition 51 underline the severity of the problem of appetite loss after gastric surgery. Here, “eating post surgery was no longer experienced as spontaneous and enjoyable, but … a regimented, planned and conscious activity” 52.
Colorectal Surgery
Appetite loss after colorectal surgery was generally rather mild 53. Some patients reported pre- operative appetite loss 54 or even an improvement in appetite for the first few months after surgery, when compared to baseline measurements 55–58. However, even in an enhanced recovery program, up to 55% of patients suffered from partial or total appetite loss two weeks after surgery 59. Postprandial appetite was also reported as lower than that of healthy controls as late as two to four years after partial or total colectomy 60.
Regarding surgical approach, appetite was better two days, two weeks, or two months after laparoscopic versus open surgery for colon cancer in a randomized controlled trial 61. Another non-randomized study on elderly patients could not reproduce these results one month postoperatively, but found an insignificant tendency towards more appetite loss in patients older than 70 years 62. Further reduction of access trauma with single versus multi port
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laparoscopic surgery showed no difference in appetite loss 1, 6, and 12 months after surgery between both groups, but worse appetite loss for single port surgery after 3 months, which the authors attributed to potential confounding from adjuvant chemotherapy 63. In contrast, another study found that adjuvant chemotherapy after colorectal surgery for cancer had no additional negative effect on appetite 64. Surgical trauma in patients with N0 rectal cancer who have had neoadjuvant radio-chemotherapy can be further reduced with endoluminal loco-regional resection by transanal endoscopic microsurgery. When compared to patients treated with laparoscopic total mesorectal excision, transanal endoscopic microsurgery resulted in significantly less appetite loss at 1 and 6 months 65, but was comparable one and three years after surgery 66.
After rectal cancer surgery, patients with a permanent stoma had less appetite than those with no stoma. However, this effect disappeared after adjustment for age and gender 67. Also, patients with temporary colostomy reported appetite loss more often than patients with temporary ileostomy 68.
Pancreatic Surgery
On a population-based level, 65% of patients suffer from appetite loss after pancreaticoduodenectomy for pancreatic adenocarcinoma 69. Appetite loss is one of the main contributors to impaired quality of life following pancreatic surgery; however, this issue improves beginning 3 months after surgery, thus resulting in an improved quality of life at that point 70,71. Nevertheless, appetite loss has been reported to be among the most prevalent and severe symptoms in pancreatic cancer patients in a post-surgical follow up of nine months 72. Other authors have also reported appetite loss following pancreatic surgery, but with symptom scores returning to preoperative values as early as 6 weeks after surgery, and with no difference between patients with or without major complications 73. When comparing different types of pancreatic surgery, appetite loss was worse after distal pancreatectomy than pancreatoduodenectomy at a median follow-up of 3.5 and 5 years, respectively 74. Pylorus- preserving pancreaticoduodenectomy for duodenal papilla carcinoma resulted in less appetite
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loss than conventional pancreaticoduodenectomy at three and six months post-op, but appetite loss was similar in both groups 24 months after the operation 75. A small series of duodenum and ventral pancreas preserving pancreatectomy reported less appetite loss compared to total pancreatectomy 76. Long-term follow-up of a randomized controlled trial at 14 years revealed significantly worse appetite loss after a pylorus-preserving pancreaticoduodenectomy than a duodenum-preserving pancreatic head resection for chronic pancreatitis 77.
Other or multiple procedure studies
Apart from the above-mentioned studies, a number of studies reported appetite loss after other types of surgery or multiple types of surgery within one study. For example, almost every patient with the multi-organ disease cystic fibrosis experienced abdominal symptoms with appetite loss. Laparotomy or small bowel resection was associated with an increase in abdominal symptoms 78.
Patients with hepatocellular carcinoma often experienced lack of appetite as late as several years after treatment, which was significantly associated with a poor health-related quality of life 79.
Two studies investigated the surgical treatment of advanced colorectal cancer. Liver transplantation for non-resectable colorectal metastases resulted in no significant changes in appetite loss during a three-year follow up. However, patients with appetite loss before transplantation had a significantly lower 3-year-survival-rate 80. Patients who underwent cytoreductive therapy and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis due to colorectal cancer had no significant change in appetite loss when compared to preoperative values at three, six, and 12 months after surgery 81. A significant majority (89%) of patients who underwent cytoreductive therapy and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei reported a healthy appetite
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afterwards, but patients that had redo procedures often reported having a worse appetite than those who had a single procedure 82.
Patients with pelvic exenteration for gynacological malignancies reported significant discomfort caused, among other reasons, by appetite loss at least 12 months after surgery 83. A study on patients undergoing major upper gastrointestinal surgery (esophagus, stomach or pancreas) reported no significant change in appetite loss compared to preoperative values at three and 12 months, but more than 50% of patients reported that appetite was not the same as it was before the operation. This finding may be due not only to appetite loss already caused by the underlying malignant disease, but also by additional changes resulting from the operation itself 84. Another study on non-metastatic digestive tract cancer including colorectal, gastroesophageal, and pancreaticobiliary cancer, appetite loss was among the most common disease-specific symptoms reported by patients in the immediate postoperative period.
Patients operated for gastroesophageal cancer suffered significantly more from appetite loss than patients who had surgery for colorectal cancer 85.
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