Is pancreas and/or spleen resection required in total gastrectomy for advanced gastric cancer?

OBJECTIVE

Total gastrectomy for advanced gastric cancer is frequently combined with extended lymphadenectomy. This technique is easier when resection of distal pancreas and/or spleen is performed. We have tried to evaluate whether the resection of both structures and total gastrectomy in patients with advanced gastric cancer actually improve survival rates.

PATIENTS

From 1991 to 1999, 140 patients with advanced gastric cancer underwent total gastrectomy at the General Hospital of Albacete: 43 with simple total gastrectomy, 57 with total gastrectomy plus splenectomy and 40 with total gastrectomy plus distal pancreaticosplenectomy. Univariate and multivariate analysis were conducted in order to evaluate different prognostic factors and survival curves among the groups.

RESULTS

Survival rates of the three groups were compared for each factor, being only significant variables the degree of tumor infiltration in the gastric wall, the size of the tumor, the staging and the type of lymphatic infiltration. Neither splenectomy nor distal pancreaticosplenectomy improved the survival compared to simple total gastrectomy. Morbimortality rates increased with more aggressive surgical procedures, but differences were not significant.

CONCLUSIONS

Resection of distal pancreas and/or spleen plus total gastrectomy for advanced gastric cancer is associated to a greater number of isolated lymph nodes, but do not improve the survival of patients.

Operative mortality with elective surgery in older adults

CONTEXT

For patients considering elective major surgery, information about operative mortality risks is essential for careful decision making. Because available information is often limited to educated guesses or optimistic data from case series, we examined surgical mortality by using nationwide data.

PRACTICE PATTERN EXAMINED

Operative mortality in 1.2 million patients in the Medicare system who were hospitalized between 1994 and 1999 for major elective surgery (six cardiovascular procedures and eight major cancer resections).

DATA SOURCE

MEDPAR file of the National Medicare claims database for patients 65 years of age and older.

OUTCOMES

Operative mortality, defined as death within 30 days of the operation or death before discharge.

RESULTS

Overall operative mortality varied widely according to procedure. Procedures associated with relatively low mortality risk included carotid endarterectomy (1.3%) and nephrectomy (2.3%). Overall mortality was greater than 10% for other procedures, such as mitral valve replacement (10.5%), esophagectomy (13.6%), and pneumonectomy (13.7%). In general, mortality risk increased with age. Operative mortality for patients 80 years of age and older was more than twice that for patients 65 to 69 years of age.

CONCLUSION

Population-based operative mortality for major surgery varies by procedure and patient age and is considerably higher than that typically reported in case series and trials.

Risk factors for complications following resection of large gastric cancer

BACKGROUND

Although there is a low mortality rate after gastrectomy in Japan, most studies include many early gastric cancers. There have been few studies on the morbidity after gastrectomy for advanced gastric cancer. The aim of this study was to clarify the characteristics and risk factors for postoperative complications after resection of large gastric cancers based on three clinical factors: patient, operation and tumour.

METHODS

A retrospective study was carried out on 97 patients with a gastric tumour measuring 10 cm or more in diameter. Postoperative complications were recorded and the patients were divided into two groups: 38 with complications and 59 without. Patient, operative and tumour findings were compared between the two groups.

RESULTS

Overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 0.01), blood loss (1338 versus 782 ml, P < 0.01), pancreatic invasion (26 versus 8 per cent, P < 0.05) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 0.05), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease.

CONCLUSION

Even in Japan, the morbidity of gastrectomy for large gastric cancer is high and associated with operating time, blood loss, pancreatic invasion and serum CEA level.

Is D2 lymphadenectomy in gastrectomy safe with regard to the skill of the operator?

BACKGROUND/AIMS

D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival benefit in the West. Recent western studies, however, especially from specialist centers, have shown a survival benefit and the safety of D2 gastrectomy. The aim of this study is to clarify the safety of D2 gastrectomy (defined by the Japanese Research Society for the Study of Gastric Cancer), even if carried out by a junior surgeon, and to show that it is not a particularly difficult or special procedure.

METHODS

Patients who underwent a typical distal gastrectomy (DG) with D2 resection (n = 344) and total gastrectomy (TG) with D2 resection (n = 111) were analyzed. The subjects were divided into 3 groups according to the postgraduate year of the operator (group I = the surgeon's postgraduate experience was less than 5 years; group II = surgeons with more than 5 years and less than 10 years postgraduate experience; group III = surgeons with more than 10 years postgraduate experience). The rate of postoperative complications and the 5-year survival rate were compared among the 3 groups.

RESULTS

The overall operative mortality rate, hospital death rate and the overall rate of postoperative complications were 1.2, 2.0 and 10.2% in DG patients, and 14.4, 0 and 1.8% in TG patients, respectively. There was no significant difference in the operative blood loss, the rate of operative mortality, hospital death rate and postoperative complications among the 3 groups. There was no significant difference in the 5-year survival rate among the 3 groups in each stage.

CONCLUSION

The postoperative mortality rate, morbidity rate and 5-year survival rate after a typical D2 gastrectomy were independent of the experience of the operator. It is considered to be a safe and useful procedure in view of the rate of postoperative complications and the long-term survival rate, even if performed by a junior trainee under the supervision of experienced surgeons in a nonspecialized hospital.

Palliative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

Although palliative gastrectomy for advanced gastric cancer may be favorable in selected patients presenting with bleeding and obstruction, little has been reported about the clinical significance of palliative gastrectomy, including prognosis.

METHODOLOGY

A retrospective comparison between 84 patients with palliative gastrectomy (PG group) and 100 patients with unresectable operation (UO group) for advanced gastric cancer was carried out.

RESULTS

The incidence of serosal invasion, peritoneal dissemination, hepatic and lymph node metastases, and undifferentiated tissue type in the UO group were significantly higher than in the PG group. Median survival after operation in the PG group (20.6 months) was significantly longer than in the UO group (5.7 months). Also, in stage IVb patients, median survival time in the PG group (10.2 months) was significantly longer than in the UO group (5.0 months). However, median survival in the patients with synchronous liver metastasis between PG (8.4 months) and UO (4.6 months) groups was not significantly different. Survival rates after operation of 6 months, 1 year and 2 years in all patients between the palliative gastrectomy group versus UO group were 83.6% versus 38.3% (P < 0.01), 63.0% versus 9.3% (P < 0.01) and 35.2% versus 0% (P < 0.01), respectively.

CONCLUSIONS

Palliative gastrectomy compared to unresectable operation may be effective for improvement of prognosis even if stage IVb patients with peritoneal dissemination and/or distant lymph node metastasis. However, it may be unfavorable on survival of patients with synchronous liver metastasis.

Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Based on a series of successful outpatient laparoscopic cholecystectomies, day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997. The initial results are reported.

METHODS

Inclusion criteria were American Society of Anesthesiologists grade I-II, living within 30 min travel from the hospital, and adult company at home. Initially only selected patients were offered day-case treatment, but later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil, and were given ketorolac, propacetamol, droperidol and ondansetron as prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rosetti fundoplication or semifundoplication depending on oesophageal manometric results.

RESULTS

Forty-five patients were included. Four patients were admitted; 41 were discharged as planned 3-8 h after operation, and five of these patients were readmitted. One underwent reoperation for necrosis of the gastric fundus. A further five patients visited the outpatient department without need for admission. At follow-up 31 patients were satisfied with the day-case treatment, five were indifferent, and five were dissatisfied because of pain. If offered a similar operation in the future, 26 patients would have preferred and seven would have accepted day-case treatment, and eight would not.

CONCLUSION

Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.

Risk factors related to operative mortality and morbidity in patients undergoing emergency gastrectomy

BACKGROUND

Emergency gastric resection for complicated peptic ulcer and gastric cancer is a major challenge for general surgeons. This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome.

METHODS

A total of 82 consecutive patients who underwent emergency gastrectomy were studied. The following variables were assessed: pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome.

RESULTS

There were 64 men and 18 women with a median age of 62 (range 30-90) years. The indications were bleeding and perforated gastric or duodenal ulcers in 45 and 20 patients respectively, and bleeding and perforated gastric tumours in seven and ten patients respectively. The overall mortality rate was 17 per cent (n = 14). The complication rate was 63 per cent and 11 patients (13 per cent) required reoperation. By multivariate analysis, age greater than 65 years and blood haemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Postoperative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death.

CONCLUSION

Age more than 65 years, haemoglobin level less than 10 g/dl and hypotension on admission were associated with a poor outcome after emergency gastrectomy. The operative result was not affected by the underlying gastric pathology.

Lymphatic involvement in early gastric cancer: prevalence and prognosis in France

BACKGROUND

The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis.

HYPOTHESIS

The main prognostic factor of EGC in patients in France is lymphatic involvement.

DESIGN, SETTING, AND PATIENTS

From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996.

MAIN OUTCOME MEASURES

The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement.

RESULTS

The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion (P =. 05) and histologic undifferentiation (P =.03). Lymphatic vessel involvement correlated positively with lymph node involvement (P =. 003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [P =.42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P =.006) and multivariate analysis (P =.01). Submucosal invasion was a prognostic factor independent of lymphatic involvement (P =.05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate (P =.21) or multivariate (P =.31) analysis.

CONCLUSIONS

Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.

Postsurgical sequential methotrexate, fluorouracil, and leucovorin for stages 3 and 4 gastric carcinoma: A preliminary study

BACKGROUND AND OBJECTIVES

The present study compared the effects of sequential methotrexate and fluorouracil followed by leucovorin rescue (MFL), as an adjuvant chemotherapy vs. UFT (a combination of uracil and tegafur), on patient survival and recurrence following surgery for advanced gastric carcinoma.

METHODS

Between July 1990 and June 1998, a total of 54 patients with advanced gastric cancer were treated postoperatively by adjuvant chemotherapy using MFL or UFT. Surgical treatment was performed according to standardized procedures for radical resection of gastric cancer. The patients were stratified into two groups following surgery. The MFL regimen consisted of methotrexate (100 mg/m2) and 5-fluorouracil (600 mg/m2) at hour 3, followed by leucovorin rescue. The oral UFT (375 mg/m2/day), a combination of tegafur and uracil in a molar ratio of 1:4, was continued for 3 years or longer depending on the patients tolerance.

RESULTS

In stage 3 gastric cancer, the overall survival rates following surgery was significantly (p < 0.05) higher in the MFL than the UFT group. Difference in disease free survival was not statistically significant between the groups. Recurrence rates showed a trend (p = 0.08) to decrease in the MFL than the UFT group. In stage 4 gastric cancer, no significant difference was obtained in the overall survival rates between the groups.

CONCLUSIONS

The present results suggested the superiority of MFL treatment for improving postoperative survival in patients with advanced gastric cancer, in particular for those patients with a high risk of recurrence following potential curative resection. In patients with stage 4 gastric cancer, however, MFL treatment showed similar effects as UFT on the postsurgical survival of the patients.

Improvement of operative mortality after curative resection for gastric cancer: population-based study

It is not well known if the improvement in operative mortality after surgery for gastric cancer reported in hospital series can be extrapolated to the whole population. The aim of this study was to determine trends in operative mortality over a 20-year period in a nonselected community-based series of patients. A database of 648 patients with gastric cancer resected with curative intent between 1976 and 1995 in a region with a half-million population was divided into two periods: 1976-1983 and 1984-1995. Nonconditional logistic regression was performed to estimate the independent effects of the studied factors. Operative mortality was higher during the 1976-1983 period than during the 1984-1995 period (17.1% vs. 7.1%; p < 0.0001). When comparing the two study periods, operative mortality decreased dramatically from 26.2% to 10.0% in patients over age 70, from 31.8% to 7.9% after total gastrectomy, and from 30.7% to 6.3% after proximal esophagogastrectomy. Operative mortality after total gastrectomy was nearly the same as that after distal gastrectomy (7.9% vs 5.9%) during the second study period. During the first study period, operative mortality was independently associated with age at diagnosis, type of gastrectomy, and to a lesser degree stage at diagnosis; during the second study period, only age and stage at diagnosis were associated with the risk of operative mortality. This study indicates that in this well defined population operative mortality after curative resection for gastric cancer has decreased during the last 20 years. The results should encourage aggressive management of patients with gastric cancer, even in patients over 70 years of age.

A prospective study of gastric cancer. 'Real' 5-year survival rates and mortality rates in a country with high incidence

A consecutive prospective series of gastric cancer patients treated in our department from January 1982 to December 1990 is presented. There was complete follow-up (100%) for a minimum of 5 years or until death. Of the 286 patients, 222 (78%) were operated. Of these, 134 (60%) were resected; 91 with curative intent (68% of resected, 32% of all cases). The cancers were of the intestinal type (differentiated) in 63%, diffuse (undifferentiated) in 22%, and indeterminate in 15% (Laurèn classification). The tumor was located in the upper third, in the middle third and in the lower third in 33. 6, 22 and 34.6%, respectively, and involved all of the stomach in 9. 8% of the cases. The gastric and lymphatic resection was performed according to The General Rules for Gastric Cancer Study in Surgery and Pathology of the Japanese Research Society for Gastric Cancer (D2 type of lymph node dissection). The operative mortality for curative resections was 6.5% (9.5% for total gastrectomy and 4.1% for subtotal gastrectomy). The operative mortality for total gastrectomy decrease from 14.3% in the first 4 years of the study to 7.1% in the last 5 years. Patients dying in the immediate postoperative period were not considered for the analysis of survival rates in operated cases. The 5-year survival rate was 12.2% for all cases (35/286). No patient without surgery or operated but not resected lived for 2 years. The 5-year survival rate in resected cases was 30% (35/118). 41.2% for curative resections (35/85) and 0% for palliative resections (0/33). The 5-year survival rate according to depth of penetration in the stomach wall for curative resections was 94.1% (16/17) in early gastric cancer (mucosal and submucosal limit), 44.4% (8/18) in tumors with muscular involvement, and 22% (11/50) with serosal extension. Early gastric cancer represented 19% (17/91) of the curative resections (6% of all cancers). The 5-year survival rate for all curative resections was 51% (24/47) for subtotal gastrectomies and 29% (11/38) for total gastrectomies. The distribution of early and advanced cancers in each group was 13/47 in subtotal gastrectomies and 4/38 in total gastrectomies. The 5-year survival rate for curative resections in advanced cancer (early gastric cancer excluded) was 35% (12/34) for subtotal gastrectomies and 21% (7/34) for total gastrectomies. In our community gastric cancer continues to be a highly lethal disease with an overall mortality from the disease or its therapy of 88% by 5 years, with the majority of cases presenting late, being only one third of all patients amenable to curative resections. However, long-term results have improved substantially since previous studies. The increased number of curative resections and its better survival rates, the increased number of early gastric cancers and an important decrease in operative mortality for total gastrectomies accounts for these results. Decreased survival rates in patients with cancers in the two upper thirds of the stomach, independent of the depth of the involvement, was seen.

Gastrectomy in the rat using two modifications of esophagojejunal anastomosis. general status, local histological changes and relationships to bone density

Gastrectomy (GX) was carried out in the male rat according to the Longmire and the Roux-en-Y procedure. The focus of the postoperative investigations was to evaluate the influence of post-GX morphological changes occurring at the site of two types of end-to-end esophagojejunal anastomosis (with and without invagination), in particular food intake, body weight gain, food efficiency, hematocrit and bone density. GX failed to alter food intake, fasting blood glucose, alpha-amino nitrogen, or free fatty acids, but led to uniformly decreased body weight, food efficiency and serum gastrin, and increased serum osteocalcin, indicating high turnover osteopenia. However, irrespective of the type of (digestive tract) reconstruction (Longmire or Roux-en-Y), the invagination anastomosis was associated with lower mortality, fewer complications, less early postoperative weight loss, less intensive tissue changes at the anastomotic site, and improvement of bone density and hematocrit. Bivariate and multivariate regression analysis revealed that bone density was negatively influenced by epithelial hyperplasia of the anastomotic tissue, while hematocrit was positively influenced by bone density. In contrast, food intake appeared to have no influence. It was concluded that (1) the histological status of the esophagointestinal anastomosis varies depending on the surgical technique applied and (2) the type of anatomical reconstruction of the digestive tract (Longmire vs. Roux-en-Y) and food intake may be of minor importance for the bone and hematological status of GX rats. Future investigations are justified to clarify whether esophagojejunal proinflammatory tissue factors may contribute to the GX-mediated damage of bone mineral and bone marrow, thereby leading to low body weight.

Clinicopathologic findings and results of surgical treatment in cardiac adenocarcinoma

BACKGROUND AND OBJECTIVES

There is a great deal of controversy regarding the definition, classification, and staging of cardiac adenocarcinoma (CA). Recently, a shift from distal to proximal lesions has been documented in gastric cancer. We have stratified our cases of gastric cancer as CA, distal gastric cancer (DGC), and stump cancer (SC).

METHODS

Between 1986 and 1998, 450 patients with gastric cancer were operated on at our institute. The resectability rate was 81.6%. Of 367 patients, 48 were CA, 298 DGC, and 21 SC. These 3 groups were compared in terms of clinicopathologic factors and survival rates.

RESULTS

CA was significantly higher in male patients and showed a prevalence of the Lauren intestinal type. Regarding staging parameters, CA showed a higher rate of T3 tumors and of resection line involvement. Five-year survival rates were 23. 2% for CA, 45.0% for DGC, and 17.4% for SC.

CONCLUSIONS

A possible cause of the poor outcome of CA is presentation at a more advanced stage. CA was similar to SC as far as epidemiology, pathologic factors, and survival rates.

Result of 11,946 gastric cancer treatment with immunochemosurgery

Although the therapeutic results of gastric cancer have markedly improved, it still remains the most common of cancer deaths in Korea. Annually more than 700, and all together 11,946, gastric cancer patients were surgically treated from 1970 to 1998 at Seoul National University Hospital. Stage III gastric cancer is already a systemic disease, Radical surgery alone cannot cure the patient, and about 35% recurred within 2-3 years. To improve the prognosis of advanced gastric cancer, systemic treatment such as immunotherapy and chemotherapy is required in the early postoperative period to kill the micrometastatic or remaining cancer cells after curative resection. We evaluated the survival rate and prognostic factors for 9,262 consecutive patients from 1981 to 1996. The clinicopathologic variables used for evaluating prognostic values were classified into patient, -tumor- and treatment-related factors. The prognostic significance of treatment modality was evaluated in stage III gastric cancer. The five-year survival rates were 55.9% for overall patients and 64.8% for patients who received curative resection. Radical lymph node dissection was found to produce survival gains in patients with stage II and IIIa. For postoperative adjuvant therapy, immunochemotherapy was most effective in patients with stage III. In multivariate analysis, curability of operation, depth of invasion, and ratio of involved-to-resected lymph nodes were the significant prognostic factors. Consequently, early detection and real curative resection with radical lymph node dissection, followed by immunochemotherapy (particularly in patients with stage III gastric cancer) should be recommended as a standard treatment principle for patients with gastric cancer.

Preoperative multivariate prediction of morbidity after gastrectomy for adenocarcinoma

BACKGROUND

Gastrectomy remains the only curative treatment for gastric cancer. However, surgical morbidity and mortality remains high. Our aim was to identify the risk factors that determine operative morbidity and mortality and to describe a simple method for preoperative stratification of morbidity outcome.

METHODS

Retrospective review of patients who underwent gastrectomy for gastric cancer. Multivariate analysis was used to define risk factors for surgical morbidity and mortality.

RESULTS

A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19 surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin (RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR, 1.51) were the most important risk factors for morbidity. However, location of the tumor, serum albumin level, and lymphocyte count were the most important preoperative risk factors that determine the appearance of surgical complications. Receiver operating characteristic analysis of this model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and 52.4%, respectively).

CONCLUSIONS

A new method for preoperative calculation of the probability of surgical complications was developed. It must be validated prospectively and in different settings to be used in preoperative interventions designed to reduce that risk.

Surgery for gastric carcinoma in patients more than 85 years of age

BACKGROUND

The incidence of gastric carcinoma is increasing in elderly patients. It has not been determined whether surgery improves the quality of life or prolongs survival in patients older than 85 years. This study was designed to evaluate surgery as a treatment option in patients more than 85 years of age.

METHODS

The records of 18 patients aged 85 to 91 years (mean 87.3 years), who underwent surgery for gastric carcinoma between 1983 and 1997 were analysed.

RESULTS

Three patients had multiple lesions. A total of 21 lesions were examined. Operative procedures included distal gastrectomy (n = 12), total gastrectomy (n = 4), proximal gastrectomy (n = 1), and laparoscopic wedge resection (n = 1). Perigastric lymphadenectomy was performed in 15 patients. No lymph node dissection was performed in three patients. Postoperative complications, including delirium, respiratory dysfunction, cardiac dysfunction, anastomotic leakage, bleeding, and ileus, occurred in 11 patients. There were two hospital deaths in patients who underwent emergency surgery. Survival was neither shortened nor prolonged by surgery as determined by life table analysis.

CONCLUSIONS

Surgical treatment should not be avoided based solely on the age of the patient, and quality of life in this population may be improved by surgery. Careful patient selection should include an assessment of the will to live.

Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy

OBJECTIVES

To examine the safety of transthoracic esophagogastrectomy (TTE) in a multidisciplinary cancer center and to determine which clinical parameters influenced survival and the rates of death and complications.

SUMMARY BACKGROUND DATA

Although the incidence of cancer at the gastroesophageal junction has been rising rapidly in the United States, controversy still exists about the safety of surgical procedures designed to remove the distal esophagus and proximal stomach. Alternatives to TTE have been proposed because of the reportedly high rates of death and complications associated with the procedure.

METHODS

Data from 143 patients treated by TTE by one author (1989-1999) were entered into a computerized database. Preoperative clinical parameters were tested for effect on death, complications, and survival.

RESULTS

The patient population consisted of 127 men and 16 women. One hundred twenty-one patients had a history of tobacco abuse, and 118 reported the regular ingestion of alcohol. One hundred fifteen patients had adenocarcinoma, 16 had squamous cell cancer, 6 had another form of esophageal tumor, and 6 had high-grade dysplasia associated with Barrett epithelia. Fifty-six patients had adenocarcinomas arising in Barrett epithelium. Twenty-eight patients were treated with neoadjuvant chemoradiation before surgery. Three patients died within 30 days of surgery (mortality rate 2.1%). Five patients (3.5%) had a documented anastomotic leak; three died). Overall, 42 patients had complications (29%). Twenty-six had pulmonary complications (19%). The mean length of stay in the intensive care unit was 3.35 days; the mean hospital length of stay was 13.54 days. The overall 3-year survival rate was 29.6%.

CONCLUSIONS

A high ASA score and the development of complications predicted an increased length of stay. The presence of diabetes predicted the development of complication and an increased length of stay. None of the other parameters tested predicted perioperative death or complications. Only disease stage, diabetes, and blood transfusion affected overall survival. From these results with a large series of patients with gastroesophageal junction cancers, TTE can be performed with a low death rate (2.1%), a low leak rate (3. 5%), and an acceptable complication rate (29%).

Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly

Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged >/= 65 years (1987-1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41. 3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10. 1% vs. 3.5%; p = 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.

Adverse operative risk factors for perforated peptic ulcer

INTRODUCTION

Mortality from perforated peptic ulcer still remains high as a result of more perforations in the elderly who are generally more ill. We conducted this retrospective study to determine the adverse operative risk factors for perforated peptic ulcers.

MATERIALS AND METHODS

Two hundred and six consecutive patients operated for perforated peptic ulcers from 1 January 1993 to 31 December 1997 were reviewed.

RESULTS

Majority (n = 194) of the patients had perforations at the pyloroduodenal region and the remaining 10 patients had perforated benign gastric ulcers. The median age at surgery was 58 years (range 18 to 91 years). Forty-four patients (21.4%) were more than 70 years old. The 30-day operative mortality rate was 10.7% (n = 22). Advanced age (> 70 years), female gender, concurrent major medical illness, perforation developed while hospitalised for other medical illnesses, prolonged perforation (> 24 hours) and preoperative hypotension (systolic blood pressure < 90 mmHg) were indicators for operative mortality by univariate analysis. By logistic regression analysis, only concurrent major medical illness, prolonged perforation and preoperative hypotension were independent adverse risk factors. The operative mortality rate for patients with 0, 1, 2 and 3 independent adverse risk factors were 0%, 11%, 30% and 88%, respectively.

CONCLUSIONS

As concurrent medical illness is a non-modifiable factor and preoperative hypotension is usually resulting from treatment delay and inadequate resuscitation, emphasis should place on shortening the time to surgery as well as prompt resuscitation.

Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma

AIMS

The management of anastomotic leakage of the oesophago-jejunostomy after total gastrectomy for gastric carcinoma was evaluated in a retrospective study.

PATIENTS AND METHODS

Over a 30-year period, a total of 1114 oesophago-jejunostomies were performed during total gastrectomy for gastric cancer. In 83 cases (7.5%) a leak of the oesophago-jejunostomy was diagnosed.

RESULTS

Frequency of anastomotic leakage was independent of the type of reconstruction and of surgical radicality. Therapeutic management was conservative in 58 cases (69.9%), with placement of a naso-jejunal tube along the anastomoses and with percutaneous drainage of intraabdominal abscesses. In 25 patients re-operation with resuturing of the anastomoses or surgical drainage of an abscess was performed. Mortality was 11/58 (19%) after conservative treatment of the anastomotic leakage and 16/25 (64%) after re-operation.

CONCLUSION

Conservative management with a naso-intestinal tube and percutaneous drainage of intraabdominal abscesses is realistic for anastomotic leaks. Re-operation results in a high morbidity and should only be considered when conservative management is not successful.

Influence of surgery on outcomes in gastric cancer

Surgery is the only possible curative treatment for gastric cancer. Although outcomes over the years have improved, there are still many controversies in the treatment of gastric cancer. One highly controversial topic is the extent of the operation. Results of recently performed large randomized studies may cause some policies to change. This article addresses the influence of surgery on outcomes of D1-D2 dissections, total versus subtotal gastrectomy, and pancreas and spleen resection and staging. Furthermore, several aspects of patient selection, the surgeon as a prognostic factor, noncurative treatment, and chemotherapy are discussed.

Surgical approach and results of surgery in adenocarcinoma of the gastro-oesophageal junction

AIM OF STUDY

This paper attempts to determine the appropriate surgical procedure in relation to the pathological types of adenocarcinoma of the gastro-oesophageal junction in Singapore.

METHODS

Data on population characteristics, clinical presentation, pathology, surgical procedures and results of treatment were gathered from the case records of a personal series of 32 patients resected for adenocarcinoma of the gastro-oesophageal junction.

RESULTS

The 32 patients with adenocarcinoma of the gastro-oesophageal junction (Type I, 9; II, 20 and III, 3), presented at a late stage (Stage I-II, 5; III, 14; IV, 13). In 19 patients with Stages I-III disease, attempted curative surgery was performed--extended total gastrectomy for Types II and III disease (13 patients) and oesophagectomy for Type I (6 patients). There was one operative mortality following curative resection. Palliative resection was performed on 13 patients with Stage IV disease with one operative mortality. The main operative morbidity was anastomotic leakage, occurring in 5 patients; both operative deaths were associated with this complication. The actuarial 5-year survival was 20%.

CONCLUSION

Although gastro-oesophageal cancer presents late, it can be resected safely by extended total gastrectomy for Types II and III disease and oesophagectomy for Type I disease, taking precautions to minimise anastomotic leakage. Although usually palliative, Stages I and II and to a lesser extent Stage III, are curable by these surgical procedures which ensure a tumour free surgical margin and adequate lymphadenectomy.

Total thoracic oesophagectomy for oesophageal carcinoma: has it been worth it?

OBJECTIVE

Anastomotic recurrence is a major cause of late mortality following oesophago-gastrectomy (OG) for carcinoma of the oesophagus and oesophago-gastric junction using either the Ivor Lewis or left thoraco-abdominal approach with intra-thoracic anastomosis. The aim of this study was to determine whether the more extensive total thoracic oesophagectomy (TTO) with cervical anastomosis would reduce the anastomotic recurrence rate while maintaining acceptable operative morbidity and mortality.

METHODS

From January 1988 to December 1996, 108 total thoracic oesophagectomies and 66 oesophago-gastrectomies were performed with curative intent in 174 patients (125 males, mean age 62.4 years) with carcinoma (squamous cell carcinoma in 34 and adenocarcinoma in 140) of the middle (31 patients) and lower (44 patients) oesophagus and oesophago-gastric junction (99 patients).

RESULTS

Minor complications occurred in 37 (34%) total thoracic oesophagectomy and 18 (27%) oesophago-gastrectomy patients, major complications in 15 (14%) and 5 (8%) and peri-operative death in 5 (4.6%) and 7 (11%) patients, respectively. Anastomotic leakage occurred in 10 (9%) total thoracic oesophagectomy and 5 (8%) oesophago-gastrectomy patients, and was fatal in 1 (1%) and 4 (6%). There was no incidence of tumour at or within 5 mm of the proximal limit in the total thoracic oesophagectomy group and this was reflected in the complete absence of anastomotic recurrence. In the oesophago-gastrectomy group there was a positive proximal resection margin in 13 (20%) and 13 anastomotic recurrences (22% of peri-operative survivors). The 5-year survival (including operative mortality) was 29% for total thoracic oesophagectomy compared with 21% for the other techniques (P = 0.028 log rank test). Median survival was 25.2 months after total thoracic oesophagectomy and 15.8 after oesophago-gastrectomy.

CONCLUSIONS

Total thoracic oesophagectomy can be performed in oesophageal cancer patients with comparable morbidity to that of lesser resections. Incomplete proximal resection and anastomotic recurrence did not occur in this series of 108 total thoracic oesophagectomies and this is reflected in an increased medium term survival. The improved survival is most apparent for tumours of the oesophago-gastric junction.