Digital Rehabilitation for Gastric Cancer Surgery After Neoadjuvant Therapy

The primary outcome of the study is the postoperative morbidity rate by the Clavien-Dindo classification at 90 days postoperatively. All postoperative complications will be documented at discharge and the surgeon will record any events after discharge at the outpatient appointment 90 days postoperatively. All complications will be classified by the Clavien-Dindo classification.

In the telephone therapeutic group , patients use a rehabilitation diary to report their progress throughout the perioperative multimodal rehabilitation program. Besides, adherence is additionally assessed by researchers through a structured adherence assessment form during the scheduled weekly calls. In the digital therapeutic group, all completion data are recorded directly by the digital platform. It is measured by the completion status of the adherence assessment form or the completion data recorded by the digital platform.

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30(EORTC-QLQ-C30) includes 30 items measuring functional, symptomatic, and global quality-of-life domains.Scores are transformed to a 0-100 scale, with higher scores indicating better quality of life.

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach Cancer Module 22(EORTC-QLQ-STO22) supplement contains 22 items assessing symptoms and concerns specific to gastric cancer. Scores are transformed to a 0-100 scale, with higher scores indicating greater symptom burden.

The Postgastrectomy Syndrome Assessment Scale 45(PGSAS-45), consisting of 45 items, will be used to comprehensively evaluate postgastrectomy symptoms, digestive status, and daily life functions.All subscale scores are linearly transformed to a 0-100 range. For symptom-related subscales, higher scores indicate greater symptom burden; for functional and quality of life subscales, higher scores indicate better functioning or quality of life.

Participants will sit on a standard-height chair (43-45 cm) with arms crossed over the chest, feet flat on the floor placed shoulder-width apart and parallel. They will then complete 10 repetitions of standing up and sitting down as quickly as possible, ensuring full knee extension upon each stand. The time to complete 10 repetitions will be recorded. Each participant will perform two trials, and the best time will be recorded.

The handgrip strength test will be administered using a digital hand dynamometer. Participants will stand with the dominant upper arm held firmly against the trunk and the forearm positioned at a 90-degree angle. The gripping handle will be adjusted to a comfortable width, allowing the fat pads of the four fingers to rest securely on the handle. Participants will be instructed to squeeze the handle with maximum effort for 3 seconds. Each participant will perform three trials with adequate rest between attempts, and the average value will be recorded.

The indicator will be assessed by cardiopulmonary exercise test (CPET)

The indicator will be assessed by cardiopulmonary exercise test (CPET)

The 6MWT is conducted along a 20 meter course marked by cones. Participants are instructed to walk back and forth as far as possible within 6 minutes, and the total distance walked (calculated from the number of laps) is recorded. The test is administered following the standardized instructions recommended by the European Respiratory Society.

Frailty will be assessed according to the Fried Frailty Phenotype, which comprises five components: shrinking, exhaustion, weakness, slowness, and low physical activity. Participants meeting three or more criteria will be classified as "frail"; those meeting one or two criteria will be classified as "pre frail"; and those meeting none will be classified as "robust/non frail".

It is calculated in the standard manner as weight in kilograms divided by height in meters squared (kg/m²).

As part of standard care, patients undergo CT imaging at baseline, following neoadjuvant therapy, and during postoperative follow-up. Sarcopenia is measured at these time points using ImageJ software. At the L3 level, total skeletal muscle, subcutaneous fat and visceral fat will be measured. SMI will be calculated as follows: skeletal muscle /height(m)2. Measurements will be recorded by two individuals, one of whom will be external to the trial group.

Patients stand upright with shoulders relaxed and the right arm hanging naturally. The assessor, positions to the participant's right, wraps a measuring tape around the midpoint between the acromion and olecranon processes, ensuring it remains perpendicular to the long axis of the arm. The tape is held snug but without compressing the underlying soft tissue. The measurement is taken on the lateral aspect of the arm, with the zero end of the tape aligned under the measurement mark.

TSF is measured at the same marked midpoint on the right upper arm as MUAC. With the patients standing, a vertical skinfold parallel to the arm is gently grasped above the mark. A caliper is applied perpendicular to the fold, and the thickness is recorded to the nearest 0.1 mm before release.

IR will be measured using the homeostasis model assessment(HOMA) calculation. HOMA-IR = (fasting glucose × fasting insulin) / 22.5.

It will be measured by serum C reactive protein (CRP) level.

It is a combined score based on CRP and serum albumin level. Scores range from 0 to 2, with higher scores indicating greater systemic inflammation and poorer prognosis.

It is a combined score based on serum albumin level and total lymphocyte count. It is calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (cells/μL). Higher scores indicate better nutritional and immunological status.

It is a 14 item self report instrument comprising two 7 item subscales designed to screen for symptoms of anxiety and depression in non psychiatric medical settings. Each subscale is scored separately, providing independent measures of anxiety and depressive symptomatology while minimizing confounding from physical illness. Each item is scored from 0 to 3, with subscale scores ranging from 0 to 21. Higher scores indicate greater levels of anxiety or depression. The scale has been validated and demonstrates good reliability in clinical populations.

It comprises 10 items evaluating an individual's expectancies for positive versus negative future experiences. Each item is scored on a 5-point scale (0-4). After reverse-scoring pessimism items, total scores range from 0 to 24, with higher scores indicating greater optimism.

It is a 10-item psychometric instrument designed to assess optimistic self-beliefs in one's ability to cope with a wide range of difficult life demands. It is a well-validated and highly reliable measure of generalized self-efficacy. Each item is scored on a 4-point scale (1-4). Total scores range from 10 to 40, with higher scores indicating greater self-efficacy.

It is a standardized, generic instrument developed by the EuroQoL Group to measure health status. It provides a concise profile of health outcomes designed for use in both clinical studies and health economic evaluations. It includes five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension comprises five levels of perceived problems, ranging from no problems to extreme problems. Responses are summarized as a five-digit health profile, which can be converted into a utility index score, typically ranging from 0 to 1, with higher scores indicating better health status.

It is a 7-item scale developed to measure psychological coping resources, specifically an individual's sense of mastery or perceived control over life circumstances. It is also a validated and reliable tool. Each item is scored on a 4-point scale (1-4). Total scores range from 7 to 28, with higher scores indicating greater perceived mastery or sense of control.

It is an eight-item instrument designed to assess fear related to surgery. It consists of two subscales measuring fear of short-term and long-term surgical consequences, and has been validated as a reliable index of surgical fear. Each item is scored on an 11-point scale (0-10). Subscale scores range from 0 to 40, and total scores range from 0 to 80. Higher scores indicate greater surgical fear.

It is evaluated by gastric emptying half-time (GET₁/₂) measured via radionuclide scintigraphy.