Gastric cancer (GC) ranks as the fifth most prevalent malignancy worldwide and is also the fifth leading cause of cancer-related mortality (1). For patients with resectable disease, total gastrectomy with D2 lymphadenectomy remains the standard curative surgical approach, typically followed by gastrointestinal reconstruction (2,3). Depending on pre-operative staging and risk assessment, certain patients may receive neoadjuvant therapy, while adjuvant chemotherapy or chemoradiotherapy may be indicated based on pathological findings, in accordance with widely accepted international guidelines (2-4). According to the 8th edition of the Tumour Node Metastasis (TNM) classification, the 5-year survival rates following R0 resection have improved significantly compared to previous decades, ranging from 89.9% in stage IB cases to 20.2% in stage IIIC cases (5).

As survival outcomes have improved, health-related quality of life (QoL) has gained increasing attention in GC care, a domain historically underemphasized in surgical and oncological literature (6-8). Total gastrectomy, despite its curative intent, often leads to persistent post-gastrectomy syndromes, such as nutritional deficiencies, digestive dysfunction and psychosocial challenges, all of which can significantly impair long-term QoL (8-11). Recognising this, there is a growing emphasis on integrating QoL as a core outcome measure in both clinical trials and routine care (9,11,12). QoL may be significantly impaired even in patients with otherwise favourable clinical outcomes. Notably, QoL has been identified as an independent prognostic factor for survival, underscoring its importance in the post-operative management of patients undergoing total gastrectomy (6,12).

Given its growing clinical relevance, it is important to understand what QoL truly encompasses. QoL is a multidimensional concept that includes physical, psychological, social, and functional well-being, shaped by individual goals, cultural context, and expectations. This holistic perspective reinforces the need to balance oncological success with the overall lived experience and recovery experienced by the patient (11,12).

To measure QoL in a meaningful manner, patient-reported outcome (PRO) assessments are most commonly used, which capture the experiences of patients directly, without clinician interpretation. PRO assessments provide insight beyond clinical metrics, assisting in the evaluation of the real-world impact of surgery, as well as in both treatment decisions and long-term care strategies (6,13).

Questionnaires are essential tools for documenting the experience of a patient and assessing QoL. The most widely used instrument for patients with cancer is the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30; https://qol.eortc.org/questionnaires/) (14), a 30-item tool that evaluates multiple dimensions of QoL. It includes five functional scales (physical, role, cognitive, emotional and social functioning), a global QoL scale, three symptom scales (fatigue, nausea/vomiting and pain), and six single-item measures addressing appetite loss, diarrhoea, dyspnoea, constipation, insomnia and financial difficulties (6,9).

To complement the generic QLQ-C30, the EORTC QLQ-STO22 (https://qol.eortc.org/questionnaire/gastric-cancer-update-of-qlq-sto22/) module was developed specifically for patients with GC (15). It consists of 22 items assessing disease-specific issues such as dysphagia, early satiety, reflux, taste disturbances, eating-related anxiety, pain and body image concerns. Collectively, the QLQ-C30 and QLQ-STO22 provide both a general and a disease-specific evaluation of the QoL of patients with GC.

The Postgastrectomy Syndrome Assessment Scale (PGSAS) is a disease-specific tool developed to evaluate QoL after gastrectomy. The PGSAS-37, derived from the original 45-item version, is organised into three domains: Symptoms (oesophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhoea, constipation, dumping) plus a total symptom score; living status measures (food intake, need for additional meals, meal quality and ability to work); and QoL subscales on dissatisfaction with symptoms, meals, work and daily life (16,17).

The EuroQol 5 Dimensions (EQ-5D) is a generic, standardised instrument developed by the EuroQol Group to assess QoL across five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. It also includes a visual analogue scale for rating overall health (18).

Several other instruments have been created to assess the QoL of patients with GC, including the Short Form-36 Health Survey (SF-36) (19), the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) (11), the MD Anderson Symptom Inventory-Gastrointestinal Module (MDASI-GI) (13) and the Korean Quality of Life in Stomach Cancer Surgery (KOQUSS) (20) questionnaire. While some of these tools assess overlapping domains, others, such as the KOQUSS, were specifically designed to capture post-gastrectomy experiences. Despite validation in selected languages, the broader international use of these instruments remains limited.

It is evident that certain domains, such as physical functioning, pain and social functioning, are consistently represented across different questionnaires, allowing comparison, whereas others are unique to individual tools, capturing aspects that may not be addressed elsewhere; recognising these overlaps and distinctions is essential for meaningful interpretation and for structuring the results in a manner that facilitates cross-study and cross-instrument analysis.

Moreover, the interpretation of these questionnaires, although described in detail within the manual of each instrument, varies between tools. Each questionnaire uses a different scoring approach; for example, the PGSAS is based on raw scores, whereas the EORTC can be calculated from either raw scores or linear transformations, with a distinct transformation algorithm for each domain (9). Consequently, this necessitates separate analyses for each domain. It should be noted that higher scores do not always indicate a better QoL; for example, in symptom scales, a higher score reflects greater symptom burden and therefore poorer QoL (10,16,17,21). Certain studies have explored the use of an overall ‘summative score’ (6,22); however, the majority of researchers analyse outcomes on a domain-by-domain basis (8,9,12,15).

The aim of the present scoping review was to examine recent evidence on post-operative QoL following total gastrectomy, with a focus on both its chronological course and variations related to surgical technique. Studies published within the previous 5 years were used to reflect research conducted after major updates to GC treatment guidelines, introduced in the West in 2013(23) and in the East in 2016(24). These updates redefined the standard surgical approach by excluding routine removal of spleen and pancreas from curative total gastrectomy. Given the significance of this change, it is reasonable to expect that it has had a substantial impact on the QoL of patients with GC, making it a relevant factor to consider in recent studies. To the best of our knowledge, this is the first scoping review to specifically examine QoL following total gastrectomy in the context of the most recent major guideline updates, providing a timely perspective on outcomes in the modern surgical era.

A comprehensive search of the PubMed, Scopus and EMBASE databases was performed using combinations of the terms\total gastrectomy\,\gastric cancer\,\quality of life\,\patient-reported outcomes', as well as the names of commonly used QoL instruments (e.g., EORTC QLQ-C30, QLQ-STO22, PGSAS-37 and EQ-5D). These terms were combined using Boolean operators (AND/OR) as appropriate. To capture the most recent data, the search was limited to studies published between 2020 and 2025, with the aim of including research conducted after the most recent major updates in GC treatment guidelines. The search and initial screening were performed by the first author, and the selection of eligible studies was discussed with the co-authors. Titles and abstracts were initially screened for eligibility, followed by full-text assessments of potentially relevant studies. Any discrepancies were resolved through discussion and consensus among the authors.

The present scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (25).

Studies were eligible if they investigated total gastrectomy, reported QoL outcomes using validated questionnaires and explicitly referred to curative total gastrectomy without any additional major organ resection. Non-English-language studies, those conducted for non-oncological indications, those lacking explicit QoL outcomes, or those not exclusively focused on total gastrectomy were excluded. The search was limited to studies published from 2020 onwards to reflect contemporary clinical practice following the widespread adoption of recent guideline updates. Studies involving multivisceral resections or comparing total to subtotal gastrectomy without extractable data specific to total gastrectomy were also excluded.

Following the removal of duplicates and applying the predefined inclusion and exclusion criteria, a total of nine studies were selected for analysis, as outlined in the PRISMA-ScR flowchart (Fig. 1).

A total of nine studies met the predefined eligibility criteria and were included in the final analysis (Fig. 1). Among these, Wei et al (26) and Yan et al (27) conducted retrospective analyses comparing, among other outcomes, QoL following linear stapling (LS) vs. circular stapling (CS) for the esophagojejunal anastomosis. Wei et al (26) supplemented their assessment with the Gastroesophageal Reflux Disease Questionnaire (GERDQ) in order to more accurately capture reflux symptoms. In addition, Yan et al (27) compared intracorporeal vs. extracorporeal anastomosis, along with various anastomotic configurations, such as overlap and π-shaped, as well as the OrVil-assisted technique. Lin et al (28) compared QoL outcomes between totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG). Van der Wielen et al (29) assessed QoL outcomes between open total gastrectomy (OTG) and minimally invasive total gastrectomy (MITG) in patients with advanced GC treated with neoadjuvant chemotherapy. A similar prospective comparison between open and laparoscopic total gastrectomy was conducted by Tanaka et al (17). Saeki et al (21) correlated high-resolution manometry (HRM) findings with QoL, while Lu et al (30) retrospectively compared QoL outcomes between patients undergoing standard Roux-en-Y anastomosis (RY) and those receiving proximal jejunal pouch Roux-en-Y anastomosis (PP-RY). Kubota et al (16) compared QoL between elderly and non-elderly patients undergoing aboral pouch reconstruction. Finally, Park et al (9) conducted a prospective longitudinal study over a period of 3 years comparing QoL after total and distal gastrectomy. Although the latter study would normally be ineligible, it was the only study under consideration to present clear, separate data on chronological changes in QoL domains for the total gastrectomy subgroup. These data, which were explicitly reported and independent from the study's other outcomes, were used as a foundation for the assessment of how QoL evolved after total gastrectomy. An outline of the characteristics of the included studies is presented in Table I.

The majority of the included studies were conducted in East Asia, with the majority designed retrospectively. The timepoints for questionnaire distribution ranged from the pre-operative period up to 3 years post-operatively. In total, 990 cases were analysed in the studies. Given the exploratory nature of the present scoping review, the aim was to synthesise recent evidence and identify patterns in QoL outcomes rather than to perform a formal methodological appraisal of individual studies.

The eligible studies included in the present scoping review used various QoL instruments: EORTC QLQ-C30, QLQ-STO22, EQ-5D and PGSAS-37. Building on the observed overlap between certain domains, outcomes were organised into conceptually grouped categories to facilitate consistent comparison across instruments, with the EORTC framework used as the primary reference given its widespread use and established structure. The domains and corresponding questions from other instruments were then mapped and adapted accordingly, allowing for alignment under common thematic categories (Table II). To the best of our knowledge, this approach has not been previously described and aims to improve clarity and comparability across studies. The findings are therefore presented according to the unified domains. For each domain, a definition is provided, followed by an overview of its chronological evolution and a comparison across surgical techniques.

QoL is increasingly recognised as a key outcome in cancer care, reflecting not only treatment success but also the ability of a patient to adapt and recover following major interventions, such as total gastrectomy. While oncological results remain essential, understanding functional recovery is equally important and may guide surgical decision-making (26).

The present review found that physical, role and emotional functioning consistently declined at an early stage post-operatively, with recovery typically beginning ~6 months. The pattern observed in the present scoping review is in agreement with other mixed gastrectomy studies (12,15). While this early decline is partly expected as the body heals from a major surgery, it is also influenced by post-gastrectomy symptoms that can significantly affect daily functioning (12). Moreover, this period often coincides with the initiation of adjuvant chemotherapy or chemoradiotherapy for several patients, which can further impact QoL. While recovery to baseline values may occur by 6 months, it should be noted that baseline does not necessarily reflect an optimal state, particularly in patients with advanced disease (9,29). As highlighted in the wider literature, recognising this trajectory can support patient expectation management and inform tailored rehabilitation planning (8,9).

The present scoping review identified mixed outcomes on social functioning following total gastrectomy. The studies demonstrating an early decline are in agreement with existing literature; Hu et al (15) reported a marked decline in social functioning after surgery, particularly during the first 45 post-operative days, with subsequent improvement to near-baseline levels. Vaccaro et al (31) observed a similar pattern, suggesting that changes in body image, disruption of established routines and pleasures, and the need to adapt to new eating patterns may hinder social engagement, particularly during meals. While a decline in social functioning over time is well documented in the literature, the improvement reported in some studies, particularly at ~12-months, may reflect the gradual adaptation of patients to post-operative changes and the resumption of social activities (17,29). Surgical approach did not appear to have a consistent or statistically significant impact on social functioning. Given the multifactorial nature of this domain, including physical recovery, nutritional adaptation, emotional well-being, and social support, isolating the effect of surgery alone is challenging. Longitudinal, standardised assessment may be needed to clarify the true trajectory of social functioning after total gastrectomy.

In the present scoping review, only the studies that used the EORTC QLQ-C30 questionnaire assessed cognitive status. Of note, one study reported a measurable decline (9), while the others found no change over time or variation based on surgical technique (17,26,27,29,30). Overall, the available evidence is insufficient to draw conclusive interpretations in this domain, and several factors may account for this inconsistency. A likely contributing factor is the early timing of assessment in certain studies. This may have captured short-term post-operative cognitive dysfunction, which typically resolves within 3 months (32,33). Another contributing factor may be the limited structure of the cognitive domain within these QoL instruments, which typically includes only two questions and does not constitute a formal cognitive assessment, such as the Mini-Mental State Examination (34). As such, their sensitivity to subtle or transient cognitive changes may be limited. The aforementioned considerations highlight the need for more thoughtful application and interpretation of existing QoL tools when assessing post-operative cognitive function.

The present scoping review found no evidence of significant financial strain over time between subgroups; a non-significant trend favouring linear over circular stapler techniques may relate to the higher post-operative complication rates reported with circular stapling, including bleeding, anastomotic stenosis and dysphagia (26,27). The only study demonstrating a decrease in financial burden involved early-stage GC, suggesting the improvement may be linked to a reduced need for post-operative therapy rather than surgical approach (17). Literature on oncologic surgery for upper gastrointestinal cancers, highlights that chemotherapy, financial demands of treatment-including personal expenses, travel and accommodation for care- and other related costs, can place a considerable strain on patients' economic well-being (35,36). Given the distinct patient groups and the varied socioeconomic contexts across study sites, firm conclusions regarding the financial domain remain challenging.

Symptom trajectories appeared to vary according to patient and treatment characteristics rather than surgical approach alone. Patients with advanced-stage disease receiving adjuvant therapy experienced more prolonged fatigue, pain, diarrhoea and taste disruptions (9), whereas mixed-stage cohorts treated with neoadjuvant therapy reported earlier recovery in several domains (29). Stable or improving symptom profiles were more often observed in early-stage cohorts (17) and in mixed-stage MIS groups without chemotherapy exposure (26-28). These findings suggest that disease stage and peri-operative therapy may exert greater influence on symptom burden than surgical technique itself. Variability in follow-up schedules and symptom reporting tools further complicates interpretation, underscoring the need for longitudinal, standardised assessment to clarify how patient and treatment factors interact in shaping post-operative symptom profiles.

The observation that global QoL improved even when symptoms persisted suggests that overall well-being is not simply the cumulative effect of individual complaints, but also reflects the capacity of patients to adapt and reframe their post-gastrectomy experience. Similar findings have been described in other oncologic populations, where coping mechanisms, resilience, and social support play a decisive role in maintaining global QoL despite ongoing treatment-related burdens (35,36). This perspective highlights the importance of integrating psychosocial and rehabilitative support into survivorship care, in parallel with symptom management. While surgical modifications such as minimally invasive or pouch reconstructions may influence short-term recovery, their impact on long-term global QoL appears limited when compared with the broader determinants of adaptation and support.

Overall, the patterns observed across the included studies suggest that post-operative QoL trajectories following total gastrectomy may be influenced more strongly by disease stage and exposure to systemic therapy than by differences in surgical technique alone. Nevertheless, interpretation of the patterns observed across the reviewed studies should be undertaken with caution, as the included studies differ substantially in stage distribution, exposure to perioperative systemic therapy, and timing of QoL assessment. It would indeed be of considerable interest to better understand the independent contribution of surgical technique, systemic therapy, and disease-related factors to post-operative QoL, particularly the effect of each factor considered in isolation. In the currently available literature, however, these elements are closely intertwined within diverse patient populations, and the combination of sample size and study design limits the ability to isolate their individual effects. Further studies specifically designed to address these questions may help clarify the relative contribution of each factor.

Reviewing the current literature revealed several key concerns regarding QoL assessment following total gastrectomy. While QoL is increasingly recognised as an important component of GC care, relatively few studies consider it as a primary outcome, with the majority still focusing on traditional surgical endpoints such as complications, resection margins, and survival. When QoL is assessed, it is often used to compare surgical techniques or patient subgroups rather than to chart the full course of recovery. This tendency provides only a partial view of recovery, limiting insight into the longer-term physical, emotional and social challenges faced by patients after surgery.

Another dimension of heterogeneity relates to geography. The present scoping review found a marked imbalance in QoL research on curative total gastrectomy over the past 5 years, with the majority of studies conducted in East Asia, where GC is more common (1). While these data provide valuable clinical insight, the predominance of Asian study populations limits the generalisability of findings, particularly in culturally sensitive domains such as role functioning, dietary practices and social engagement. Notably, despite the development of one of the most comprehensive and widely validated QoL instruments for cancer patients, the EORTC QLQ-C30 and its gastric-specific module, Western centres have contributed relatively few QoL studies focused specifically on total gastrectomy. Addressing the regional imbalance requires consideration of cultural and geographical context when interpreting QoL instruments and when formulating clinical recommendations.

Building on the challenges outlined above, a major difficulty in interpreting QoL outcomes is the marked heterogeneity among available studies. This includes differences in study design, such as retrospective and prospective approaches, differences in setting between multicentre and single-centre studies and variations in focus, with certain studies comparing surgical techniques within specific subgroups. Such variability limits the generalisability of findings and complicates efforts to compare and synthesise results across the literature.

Marked variability in the timing of QoL distribution further complicates interpretation. Only a small number of studies applied questionnaires pre-operatively or in the early post-operative period (9,17,27,29), when physical and psychological effects are most acute. While certain studies tracked changes over time (9,21,17,28), others relied on a single time point (16,26,27,29,30). The fact that QoL is primarily considered in relation to long-term outcomes may explain why questionnaires are not commonly used to capture the impact of short-term complications, which are often described under the separate concept of ‘quality of recovery’ (37,38). Yet, nothing in the instrument manuals precludes their early use, leaving an opportunity to better understand the immediate post-operative experience; an approach that could yield valuable insights into the trajectory from short-term recovery to long-term well-being (12,27).

These methodological differences are further influenced by the limitations of the instruments themselves. In the present scoping review, no single questionnaire was found to be capable of comprehensively assessing QoL following total gastrectomy. The EORTC QLQ-C30, developed for patients with cancer, covers a broad range of domains, but requires the STO22 module to capture GC-specific symptoms, resulting in 52 questions, which can be burdensome for patients and may reduce response rates. Similarly, researchers using the PGSAS-37 often supplemented it with the EORTC or omitted domains, such as functioning and financial status entirely. Overlap between certain domains and omission of others not only limits comparability between studies, but also impedes the ability to track the full course of recovery. The lack of uniformity in scoring and scale direction across instruments requires familiarity with each tool's methodology, increases the complexity of analysis, and makes cross-study comparisons more difficult. The aforementioned challenges emphasise the importance of applying existing instruments within a standardised framework to minimise respondent burden while ensuring all relevant domains are assessed.

Finally, although the majority of studies reported clinical variables, such as pre-operative treatment or post-operative complications, their potential influence on QoL outcomes was rarely explored. Most importantly, none of the studies considered the impact of post-operative chemotherapy on QoL, despite its recognised effect on recovery and overall well-being. These gaps are particularly critical, given that several patients with GC may already be malnourished, anxious, or psychologically burdened at the time of diagnosis. Without consideration of these variables, QoL results may reflect not only the effects of surgery but also broader clinical and psychosocial conditions. This lack of adjustment can confound observed QoL patterns, making it difficult to separate the effects of surgery from those of the underlying disease, treatment-related side effects, or pre-existing patient conditions. To improve interpretability and comparability, future research would benefit from clearly defined assessment timelines and a systematic evaluation of pre-operative status, post-operative course, and adjuvant therapies.

The present scoping review has certain limitations. As a scoping rather than a systematic review, it may not capture all available literature despite a focused and thorough search. Additionally, by limiting inclusion to patients undergoing total gastrectomy without additional major organ resection, certain relevant data may have been excluded, potentially affecting the completeness of the findings. Finally, the inconsistency in how QoL is assessed and reported across studies makes comparison challenging and may weaken the overall interpretability of results.

In conclusion, total gastrectomy remains a life-altering procedure with long-term consequences for the daily life of a patient. Beyond survival and surgical endpoints, QoL is a critical outcome as it can influence treatment decisions and guide both clinicians and patients through post-operative challenges. A clear understanding of QoL in both the early and late phases of recovery is essential for informing expectations and optimising follow-up strategies. Equally, evaluating how different surgical techniques shape these outcomes can provide valuable guidance for shared decision-making. To achieve this, more QoL-focused studies are needed, designed to capture both chronological changes and procedure-specific outcomes across a range of cultural and clinical settings.