National Outcomes After Gastric Resection for Neoplasm

HYPOTHESIS

That factors affecting outcomes of surgical resection in the treatment of gastric cancer can be identified using a large US database.

DESIGN

Retrospective observational study.

SETTING

The Nationwide Inpatient Sample from January 1, 1998, through December 31, 2003.

PATIENTS

We included 13 354 patient discharges (approximately 66 096 nationally by weighted analysis) who underwent gastric resection for neoplasm.

MAIN OUTCOME MEASURE

In-hospital mortality. Univariate analyses were performed by means of chi(2) tests. A multivariate logistic regression was performed to determine which variables were independently predictive of in-hospital mortality.

RESULTS

During the study period, 50 738 patients (approximately 250 420 nationally) were discharged with the diagnosis of gastric neoplasm. Of those, 13 354 (26.3%) underwent gastric resection during their hospitalization. In-hospital mortality for patients undergoing surgery was 6.0%, without significant change from 1998 through 2003. Factors predictive of significantly increased in-hospital mortality included low annual hospital surgical volume (lowest [<or= 4 gastrectomies per year] vs highest [>or= 11 gastrectomies per year], 6.8% vs 4.9%; adjusted odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8]), older patient age (50-69 vs <50 years, 4.0% vs 2.1%; adjusted OR, 1.5; 95% CI, 1.1-2.2) (>or =70 vs <50 years, 8.6% vs 2.1%; adjusted OR, 2.9; 95% CI, 2.0-4.3), male sex (male vs female, 6.7% vs 5.0%; adjusted OR, 1.3; 95% CI, 1.1-1.5), and procedure type (total gastrectomy vs all other resections, 8.0% vs 5.3%; adjusted OR, 1.4; 95% CI, 1.2-1.7).

CONCLUSIONS

Higher annual surgical volume is predictive of lower in-hospital mortality for patients undergoing gastric resection for neoplasm. Other factors significantly associated with superior outcomes after gastric resection included diagnosis type, procedure type, younger age, female sex, and fewer comorbid conditions.

Cancer of the gastric stump following distal gastrectomy for cancer

BACKGROUND

Cancer of the gastric stump (CGS) after distal gastrectomy for cancer has not been characterized in a large study. The aim of this study was to investigate the clinicopathological features and outcome of CGS following distal gastrectomy for cancer.

METHODS

Patients with CGS following distal gastrectomy for gastric cancer diagnosed between 1970 and 2002 were reviewed retrospectively.

RESULTS

A total of 108 patients was identified. The median interval between the initial gastrectomy and resection for CGS was 7.5 (range 1-41) years. The depth of tumour invasion was T1 in 67 patients, T2 in 16, T3 in eight and T4 in 17 patients. Endoscopic mucosal resection was performed in 25 patients with T1 tumours. R0 resection was achieved in 103 patients. The overall 5-year survival rate was 53.1 per cent. The 5-year survival rates for patients with T1, T2, T3 and T4 disease were 76, 40, 13 and 9 per cent respectively.

CONCLUSION

The outcome for patients with non-early CGS was poor. Early detection of CGS is important following distal gastrectomy for gastric cancer and strict surveillance is recommended for at least 10 years after the initial gastrectomy.

Results following resection for stage IV gastric cancer; are better outcomes observed in selected patient subgroups?

BACKGROUND

Patients who present with stage IV gastric cancer are not commonly managed with surgical resection as effective palliation can usually be accomplished with systemic chemotherapy, endoscopic stenting, or surgical bypass procedures. Given the inherent morbidity and mortality associated with gastrectomy, palliative resection for stage IV gastric cancer should be reserved for ideal surgical candidates who are most likely to benefit from the procedure. The purpose of this study is to review outcomes following resection for stage IV gastric cancer, and to identify criteria predictive of improved outcomes following gastrectomy in this setting.

METHODS

A retrospective review of a prospective GI oncology database was conducted. Sixty-three patients with stage IV gastric cancer managed with surgical resection between 1989 and 2001 were identified. Variables including demographic data, patterns of distant spread (ex: peritoneal, lymphatic, hematogenous), location of tumor, and type of gastrectomy were utilized to conduct survival analyses.

RESULTS

Actuarial survival for all patients at one and 3-year intervals was 52% and 12%, respectively. Improved survival was observed for patients of East Asian race (median survival 20 vs. 12 months, P < 0.05, students t-test) and age less than 60 years (median survival 15 vs. 12 months, P < 0.05). This trend was also illustrated by Kaplan-Meier survival analysis. Other variables including pattern of distant spread, location of tumor, and type of gastrectomy were not associated with a significant difference in survival. Both East Asian race and age less than 60 years were statistically significant predictors of improved survival when assessed by univariate regression analysis. When variables were analyzed in a multivariate regression analysis, Asian race and age <60 both lost their statistical significance as independent predictors of improved survival.

CONCLUSIONS

Long-term survival for patients with stage IV gastric cancer who are managed with surgical resection is achievable. Patient specific variables including East Asian race and age less than 60 years appear to be associated with prolonged survival when assessed by comparison of means, Kaplan-Meier analysis, and univariate regression analysis. However, multivariate regression analysis failed to demonstrate these factors as independent predictors of improved outcome. In conclusion, highly selected acceptable risk surgical candidates with stage IV gastric cancer should be considered for management with surgical resection in clinically appropriate scenarios.

Morbidity and mortality of laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection for gastric cancer

Gastrectomy with extraperigastric lymph node dissection has not been generally acceptable because of increased morbidity and mortality in some Western countries. Recently, many surgeons have become interested in laparoscopic gastric surgery for malignant disease as well as benign lesions because laparoscopic surgery itself has been shown to have many advantages over open surgery. The aims of this study are to evaluate the incidence and nature of operative morbidity and mortality after laparoscopy-assisted gastrectomy (LAG) with extraperigastric lymph node dissection with respect to surgical experience and to identify factors predictive of complications and death. We reviewed the surgical outcomes of LAG with extraperigastric lymph node dissection in 140 consecutive gastric cancer patients. Clinicopathologic characteristics, operative outcomes, and postoperative morbidities and mortalities were compared after dividing the 140 patients into early (1-70) and late (71-140) groups. And risk factors for morbidity and mortality were identified by multivariate logistic regression analysis. The overall operative morbidity and mortality rates were 18.6% and 0.7%, respectively. Thirty postoperative complications occurred in 26 patients. The minor surgical complication rate in the late group was significantly lower than that in the early group (P = 0.0349). According to univariate and multivariate analyses to evaluate the independent predictor of a higher operative morbidity rate, no factor was significantly associated with operative morbidity. We conclude that LAG with extraperigastric lymph node dissection is a technically feasible and acceptable surgical modality for gastric cancer and low morbidity and mortality rates for this procedure can be accomplished by experienced laparoscopic gastric surgeons at large-volume hospitals.

Gastric adenocarcinoma: reduction of perioperative mortality by avoidance of nontherapeutic laparotomy

National trends indicate a longstanding decline in gastric adenocarcinoma due presumably to a decreasing prevalence of Helicobacter pylori infection. Nonetheless, surgical outcomes continue to include relatively high morbidity and mortality rates owing to the advanced stage of disease encountered. We hypothesize that recent immigration patterns are responsible for a leveling off or even reversal of the declining incidence of gastric cancer associated with H. pylori infection. Furthermore, advances in preoperative tumor staging and nonoperative palliation currently permit better patient selection for operation with lower perioperative morbidity and mortality. A retrospective review of a consecutive case series at a public teaching hospital located in an area of high immigration was conducted that included all patients presenting, from 1995 through 2004, with gastric adenocarcinoma. For time comparison purposes, patients were divided into early (1995-1999) and recent (2000-2004) periods. There was no decline in the frequency of gastric adenocarcinoma among the study population over the 10 years. A total of 260 patients were treated of whom 137 (53%) underwent operation. The operation rate decreased and the gastric resection rate increased from the early period to the recent period as fewer incurable advanced stage (M1) patients underwent exploratory laparotomy and were palliated by nonoperative means. Perioperative morbidity and mortality rates also declined over time. Of the four total perioperative deaths, two followed 11 nontherapeutic laparotomies (18% mortality), whereas the only two additional deaths followed 122 curative or palliative laparotomies (2% mortality) (p = 0.034). We conclude that in an area of high immigration there has been no decline in gastric adenocarcinoma rates over the past decade, and the marked reduction in perioperative mortality was due to near elimination of nontherapeutic laparotomy.

Prognostic significance of level and number of lymph node metastases in patients with gastric cancer

BACKGROUND

To present data that provide some insight into the appropriateness of a nodal grouping category and its relation to survival in patients with gastric cancer.

METHODS

We reviewed data of 777 patients with advanced gastric cancer who had undergone curative gastrectomy to investigate the prognostic significance of level and number of lymph node metastases.

RESULTS

The prognosis of patients with gastric cancer was well correlated with the level and number of lymph node metastases. Multivariate analysis indicated that the level and number of lymph node metastases were independent prognostic indicators. Moreover, the number of lymph node metastases was an independent prognostic factor in N1, N2, and N3 patients. The most statistically significant difference in disease-specific survival was observed at a threshold of 11 lymph node metastases, yielding a chi2 value of 42.88, a hazard ratio of 2.523, at a 95% confidence interval of 1.913, 3.329 (P < .0001) by Cox proportional hazard model. On the basis of this result, patients were divided into two groups as follows: marked lymph node metastasis group (number of positive nodes > or =11) and slight lymph node metastasis group (number of positive nodes < or =10). The prognosis of patients with marked lymph node metastasis was statistically significantly worse than that with slight lymph node metastasis in N1, N2, and N3 patients.

CONCLUSIONS

Both level and number were indispensable for evaluating lymph node metastasis. Therefore, addition of the number of positive nodes to the N category defined by the Japanese Classification of Gastric Carcinoma may be a useful strategy in the N staging classification in gastric cancer.

Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy

AIM: To elucidate the current status of laparoscopy-assisted distal gastrectomy (LADG) with regard to its short-term outcomes by comparing it with conventional open distal gastrectomy (CODG).

METHODS: Original articles published from January 1991 to August 2006 were searched in the MEDLINE, EMBASE, and Cochrane Controlled Trials Register. Clinical appraisal and data extraction were conducted independently by 2 reviewers. A meta-analysis was performed using a random effects model.

RESULTS: Outcomes of 1611 procedures from 4 randomized controlled trials and 12 retrospective studies were analyzed. Compared to CODG, LADG was a longer procedure (weighted mean difference [WMD] 54.3; 95% confidence interval [CI] 38.8 to 69.8; P < 0.001), but was associated with a lower associated morbidity (odds ratio [OR] 0.54; 95% CI 0.37 to 0.77; P < 0.001); this was most significant for postoperative ileus (OR 0.27; 95% CI 0.09 to 0.84; P = 0.02). There was no significant difference between the two groups in anastomotic, pulmonary, and wound complications and mortality. Duration from surgery to first passage of flatus was faster (WMD -0.68; 95% CI -0.85 to -0.50; P < 0.001) and the frequency of additional analgesic requirement (WMD -1.36; 95% CI -2.44 to -0.28; P = 0.01), and duration of hospital stay (WMD -5.51; 95% CI -7.61 to -3.42; P < 0.001) were significantly lower after LADG. However, a significantly higher number of lymph nodes were dissected by CODG (WMD -4.35; 95% CI -5.73 to -2.98; P < 0.001).

CONCLUSION: LADG for early gastric cancer is associated with a lower morbidity, less pain, faster bowel function recovery, and shorter hospital stay.

Mortality Increases for Octogenarians Undergoing Esophagogastrectomy for Esophageal Cancer

BACKGROUND

As the general population ages, it becomes increasingly important to understand the potential contribution of chronologic age to mortality after esophagectomy. Because this risk is poorly defined, we sought to determine whether extreme age (>80 years) is an independent risk factor after esophagectomy.

METHODS

We analyzed a prospectively maintained, single-institution database of 858 consecutive patients who underwent esophagectomy between January 1996 and May 2005. Data evaluated included patient demographics, medical comorbidity, types of resections performed, length of stay, postoperative adverse events, and overall survival. We used univariate, multivariate, and Kaplan-Meier analysis to determine the influence of age on postoperative morbidity, in-hospital survival, and overall survival.

RESULTS

Of 858 patients, 31 (10 female, 21 male) were older than 80 years of age. Preliminary analysis indicated that patients younger than 50 years (n = 107) had significantly fewer comorbidities; these were excluded from the analysis. In the remaining 751 patients, the age older than 80 cohort was compared with patients aged 50 to 79. Patients aged 50 to 79 were grouped because of similar characteristics (length of stay, hospital death). There were no significant differences in comorbidities, types of resections, or postoperative complication type or severity between the two groups. Postoperative death, length of stay, and survival, however, were significantly worse in patients older than 80. In a logistic regression model controlling for comorbidity, age older than 80 was significantly associated with increased perioperative mortality (hazard-ratio, 3.9; p < 0.01).

CONCLUSIONS

Patients older than 80 years have increased mortality risk after esophagectomy, independent of comorbidity. Octogenarian status should be a consideration in the management of these patients.

[A phase I study of intraperitoneal plus intravenous paclitaxel against gastric cancer with peritoneal dissemination (HGCG 0301)]

The safety of the intraperitoneal (ip) plus intravenous (iv) paclitaxel against gastric cancer with peritoneal dissemination was evaluated on a phase I dose escalation trial. Patients were treated with ip paclitaxel administered in 500 ml of normal saline before closing the abdomen, using the following dose levels: level 1, 50 mg/m(2); level 2, 60 mg/m(2); level 3, 70 mg/m(2); and level 4, 80 mg/m(2), followed by iv infusion of the same doses of paclitaxel on days 14 and 21. Twelve patients were enrolled in this study: 7 underwent reduction surgery,while 5 had only a laparotomy. ip therapy was well tolerated, and did not bring about any postoperative complications even in patients who underwent gastrectomy. Although multiple NCI/CTC grade 1 toxicities and grade 2 anemia (4 of six patients at dose levels 2 and 3) were observed, there was no dose-limiting toxicity. The overall median survival time was 316 days, and that for patients who underwent gastrectomy was 413 days. Paclitaxel at a dose of 80 mg/m(2) can be delivered by the operative ip route with acceptable toxicity profile.

Gastric cancer surgery in elderly patients

BACKGROUND

To investigate the value of individual risk-adapted therapy in geriatric patients, we performed a consecutive analysis of 363 patients undergoing potentially curative surgery for gastric cancer.

PATIENTS AND METHODS

All patients underwent extensive preoperative workup to assess surgical risk. The following criteria were evaluated in 3 age groups (<60 years, 60-75 years, and >75 years): comorbidity, tumor characteristics, type of resection, postoperative morbidity and mortality, recurrence rate, overall survival, and disease-free survival.

RESULTS

There was an increased rate of comorbidity in the higher age groups (51% vs 76% vs 83%; P<0.05). Cardiovascular and pulmonary diseases were most common. There was a decrease in the rate of both total gastrectomy (74%, 54%, 46%; P<0.05) and D2 lymphadenectomy (78%, 53%, 31%; P<0.05). The 30-day mortality in the 3 age groups was 0%, 1%, and 8%, respectively (P<0.05). There was only a slight difference in tumor recurrence rate (35%, 37%, and 27%; P=0.437), with no significant difference in 5-year cancer-related survival (61%, 53%, 61%; P=0.199).

CONCLUSIONS

Patient selection and risk-adapted surgery in elderly patients can result in acceptable therapeutic results comparable to younger patients. Limited surgery in elderly gastric cancer patients with high comorbidity does not necessarily compromise oncological outcome.

[Evolution of resectability and mortality rates of total and subtotal gastrectomy for gastric cancer]

BACKGROUND

The only curative treatment for gastric cancer is its surgical excision associated to a lymph node dissection.

AIM

To study the evolution of resectability and operative mortality of total and subtotal gastrectomy for gastric cancer, in a period of 35 years.

MATERIAL AND METHODS

Review of medical records of 3000 patients with gastric cancer, operated between 1969 and 2004. Resectability and mortality of total and subtotal gastrectomy was compared in four successive periods (1969 to 1979, 1980 to 1989, 1990 to 1999 and 2000 to 2004).

RESULTS

In the four periods there was a steady and significant increase in resectability rate from 49 to 85%. Mortality of total and subtotal gastrectomy decreased significantly from 17 to 2% and from 25 to 1%, respectively.

CONCLUSIONS

Resectability and mortality rates of total and subtotal gastrectomy have improved with time. Probably a better pre and postoperative care and the experience of the surgical team have an influence in this favorable change.

Extended lymph node dissection without routine spleno-pancreatectomy for treatment of gastric cancer: low morbidity and mortality rates in a single center series of 250 patients

BACKGROUND AND OBJECTIVES

To verify the hypothesis that avoidance of routine splenectomy and distal pancreatectomy in a modified D-2 resection for gastric cancer can significantly lower the complications rate of this procedure in a population of Western patients.

METHODS

A series of 250 consecutive Italian patients suffering from localized, histology-proven gastric cancer was submitted to gastrectomy and extended D-2 lymphadenectomy for treatment of their disease during an 8-year period (1994-2002) at the European Institute of Oncology in Milano, Italy. Caudal pancreas and spleen were routinely preserved, unless the tumor was not closely adjacent to or directly invading these organs. Postoperative morbidity, overall mortality, and length of hospital stay were recorded.

RESULTS

One hundred forty patients underwent total gastrectomy and 110 a subtotal distal one; splenectomy was performed in 8 cases and spleno-pancreatectomy in 15. The postoperative morbidity rate was 18%, the mortality rate was 1.2% and 9 patients experienced re-operation. The median length of stay was 14.8 days.

CONCLUSIONS

These results compete favorably with those reported after standard D-1 gastrectomy in Western patients series. D-2 gastrectomy with spleen and pancreas routine preservation can be considered a safe treatment for gastric cancer in Western patients, at least in experienced centers.

[Performing major upper abdominal operations in a low-volume hospital: is it possible?]

INTRODUCTION

The outcomes of cardio-oesophageal resection, gastric resection, total gastrectomy and Whipple's operation in a low-volume hospital over a decade are presented.

MATERIALS AND METHODS

Thirty-seven patients were followed for five years after a cardio-oesophageal resection, 21 after a Billroth II resection, 15 after total gastrectomy and 28 after a Whipple's operation. Mortality and morbidity rates, post-operative in-hospital period and long-term survival were measured.

RESULTS

Cardio-oesophageal resection: The morbidity rate was 19%, the mortality rate was 11%, and the median post-operative stay in hospital was 11 days. The five-year survival rate based on death from cancer was 37% and from all causes 32%. Gastric resection and gastrectomy: The morbidity rate was 14%, the mortality rate was 3%, and the median post-operative period in hospital was 9 days after gastric resection and 11 days after gastrectomy. The five-year survival rate based on death from was cancer 55% and from all causes 37%. Whipple's procedure: The morbidity rate was 17%, the mortality rate was 4% and the median post-operative stay in hospital was 10 days. The survival rate based on death from cancer was 77% and from all causes was 54% after five years for cancer of the ampulla of Vater, and 27% and 31% after three years for pancreatic head carcinoma.

CONCLUSION

Major gastric and pancreatic operations can be performed in a low-volume hospital with satisfactory results.

Predicting individual survival after gastric cancer resection: validation of a U.S.-derived nomogram at a single high-volume center in Europe

OBJECTIVE

Validation of a U.S.-derived nomogram for individual prediction of disease-specific gastric cancer survival at a European institution.

SUMMARY BACKGROUND DATA

One major issue of modern cancer treatment is the individualization of therapy. For gastric cancer, Kattan et al, at Memorial Sloan-Kettering Cancer Center, New York, NY, developed a nomogram, allowing to predict individual patient risk of tumor-related death after R0 resection from basic patient-related variables. The validity of the nomogram has not yet been shown in patients from other institutions. The accuracy of the nomogram when applied to patients after having undergone R0 gastric cancer resection at a European high-volume center was investigated.

METHODS

Clinical data from patients who underwent R0 gastric cancer resection at Klinikum rechts der Isar, Technical University of Munich, Germany and fitted the respective derivation criteria were used for external validation (n = 862). Nomogram predictions for 60- and 108-month disease-specific survival were calculated for each patient and compared with actual survival. The concordance index was used as an accuracy measure.

RESULTS

The bootstrap-corrected concordance index was 0.77 and was superior when compared with the predictive ability of International Union Against Cancer tumor stage (P < 0.008). Nomogram calibration was excellent for 60-month disease-specific survival. Nomogram predictions showed the trend to underestimate survival in stage II/III disease of the MRI patients.

CONCLUSIONS

The use of the nomogram created by Kattan et al is not only confined to the institution where it was created, but it can be adopted by other institutions with similar surgical strategies.

[Comparative assessment of surgical interventions for cancer of the distal part of the stomach]

The author has analyzed the nearest and long-term results of treatment of 260 patients operated on by the Billroth-I method and 220 patients operated on by the Billroth-II method. It was found that after the Billroth-I resection the frequency of disease of the operated stomach was less, the other indices such as postoperative lethality rate, complications, survival up to 10 years, had no substantial difference.

Survival of Young Patients after Gastrectomy for Gastric Cancer

It has been suggested that gastric cancer has a worse prognosis in young patients, but the data are controversial. The aim of this study was to compare the 5-year survivals after gastrectomy for gastric cancer in two groups of patients (those < or = 45 years of age and those (> 45 years) and to determine some of the prognostic factors. The 5-year survival was significantly better for patients < or = 45 years of age. Survival was also better for young patients with a curative resection and also for those with lymph node metastases. However, survival was not significantly different for the two groups when the resection was not curative and when the lymph nodes were not involved. Survival was no different for the two groups when compared at each stage, although a multivariate analysis showed that age > 45 years, moderate or poor degree of differentiation of the tumor, advanced tumors, the presence of lymph node involvement, and a noncurative resection were independent negative prognostic factors. Long-term survival after gastrectomy for gastric cancer depends on the stage of the disease; the age of the patient is not a decisive factor.

[Total gastrectomy for the surgical treatment of gastric cancer]

We review the work of professor József Imre, who had outstanding ability in surgery and also took part in organizing modern hungarian surgery of oesophagus and stomach. We present the results of operations for malignant gastric tumours performed between 1963 and 1981 in the First Department of Surgery, University Medical School of Szeged. We describe in details the typical data about total gastrectomies and compare the results with what we can achieve in our days. We compare changes in diagnosis, indications, incisions, evaluation of methods of reconstruction, postoperative death, anastomotic leak late survival for total gastrectomies.

Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors

BACKGROUND

Resection for adenocarcinoma of the gastroesophageal junction (AGEJ) is associated with severe mortality and morbidity. This retrospective study aimed to evaluate mortality and morbidity after resection for AGEJ and to determine their predictive factors.

STUDY DESIGN

Data from 1,192 patients (mean age 65 +/- 11 years) who underwent resection for AGEJ by members of French Association of Surgery from 1985 to 2000 were collected. A stepwise logistic regression model was built to identify by multivariate analysis the variables independently associated with mortality, morbidity, anastomotic leakage, and major pulmonary complications.

RESULTS

Distribution of Siewert's type was: I = 480 (40%), II = 500 (42%), and III = 212 (18%). Most type I and II tumors were treated by esophagectomy and proximal gastrectomy (93% and 58%, respectively), using an approach including a thoracotomy (82% and 64%, respectively); type III tumors were treated mainly by total gastrectomy and distal esophagectomy (83%), through an exclusive transabdominal approach (69%). Seventy-six (6%) patients died postoperatively. Only American Society of Anesthesiologists (ASA) scores III and IV (p < 0.001) and period of study (p = 0.025) were predictive of mortality. Predictive factors of overall morbidity (overall rate = 35%) were high ASA score (p < 0.001), age more than 60 years (p = 0.020), male gender (p = 0.039), and cervical anastomosis (p = 0.001). Factors predictive of anastomotic leakage (overall rate = 9%) were high ASA score (p = 0.006) and manual anastomosis (p = 0.010). Factors predictive of major pulmonary complications (overall rate = 23%) were high ASA score (p = 0.015), age more than 60 years (p < 0.001), anastomotic leakage (p < 0.001), and abdominal complications (p = 0.003).

CONCLUSIONS

ASA score is a reliable predictive factor of operative mortality and morbidity after resection of AGEJ.

[Postoperative mortality after gastrectomy for gastric cancer: analysis of 1142 cases]

OBJECTIVE

To analyze postoperative morbidity and mortality after gastrectomy for gastric carcinoma and identify main risk factors influencing mortality.

METHODS

A total of 1142 patients with gastric cancer received gastrectomy between January 1989 and April 2004. The patients were divided into three groups according to different period, the first group (n=405): from January 1989 to January 1994; the second group (n=377): from February 1994 to January 1999; the third group (n=360): from February 1999 to March 2004. Postoperative morbidity and mortality were compared among three groups, the risk factors influencing postoperative mortality were determined by multiple logistic regression analysis.

RESULTS

The total postoperative morbidity and mortality for all patients were 11.2% (128/1142) and 3.6% (41/1142), respectively. The postoperative morbidity was 13.1%, 10.1%, and 10.3% in the first, second, and third group respectively, there was no significant difference in morbidity among the three groups (P > 0.05). The postoperative mortality was 4.7%, 3.4%, and 2.5% respectively (P > 0.05), there was no significant difference in mortality among the three groups (P > 0.05). The most common postoperative complication was anastomotic leakage (24.2%, 31/128). The following clinicopathologic factors were found to be correlated with postoperative mortality: stage IV; palliative excision; multivisceral resection; and preoperative complications (P< 0.05). Multivariate analysis revealed that the extent of lymph node dissection or surgical procedure were not main risk factors influencing mortality.

CONCLUSION

Patients with advanced gastric cancer have a high risk of postoperative mortality. Unnecessary lymph node dissection or multivisceral resection should be avoided for patients with stage IV gastric cancer.

Pretreatment anemia is associated with poorer survival in patients with stage I and II gastric cancer

BACKGROUND AND OBJECTIVES

A negative correlation between anemia and outcome has been demonstrated in various cancers treated with radiotherapy. However, it is rarely studied whether this correlation may exist in surgical setting. Our aim was to investigate the relationship between pretreatment anemia and survival in surgically treated patients with gastric cancer.

METHODS

A total of 1,688 patients who had undergone curative resection for gastric cancer between 1991 and 1995 were reviewed. Anemia was defined as a hemoglobin level <12.0 g/dl. The influence of anemia on patient overall survival was evaluated by univariate and multivariate analysis.

RESULTS

Pretreatment anemia was present in 39.9% of the patients. The 10-year overall survival rate in anemic patients was 48.2% as compared with 62.6% in nonanemic patients (P < 0.001). In subgroup analysis according to the stage, the significant difference in 10-year overall survival rate between anemic and nonanemic patients was found in stage I and II gastric cancer (76.1% vs. 83.5% in stage I, P = 0.030; 55.1% vs. 67.2% in stage II, P = 0.043). On multivariate analysis, anemia was an independent prognostic predictor in patients with stage I and II disease (P = 0.007; RR, 1.466; 95% CI, 1.109-1.937).

CONCLUSIONS

Pretreatment anemia was found to have an independent relationship to the long-term survival of patients with stage I and II gastric cancer.

Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population based study

BACKGROUND

Complete surgical (R0) resection remains the only potentially curative intervention for patients with localised gastric cancer. To achieve a curative resection, patients may require complex operations with resection of contiguous organs. The aim of this study was to assess how the extent of surgical resection influenced morbidity, mortality and survival in an aged non-selected population with significant comorbid disease.

PATIENTS AND METHODS

Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of 1-year follow-up.

RESULTS

A total of 646 patients underwent surgical exploration for gastric cancer. A significantly higher incidence of chest infections (18.5 vs 11%, p< 0.05) and anastomotic leaks (14.3 vs 2.2%, p< 0.05) were associated with total gastrectomy (n=168) when compared to distal gastrectomy (n=272) resections. A 9.2% mortality rate and a 60% 1-year survival were associated with gastric resection alone. Removal of the spleen (n=131), pancreas (n=30) or liver resection (n=5) was associated with a significantly higher mortality rates, 18.3, 23.3 and 40%, respectively (p< 0.05), and significantly lower 1-year survival rates, 50.9, 39.1 and 20%, respectively (p< 0.05).

CONCLUSIONS

The risk of more extensive resection is not balanced by improved survival in this population based series. Extending gastric resection to involve contiguous organs should be confined to highly selected cases.

[Gastric resection for cancer in Denmark, 1999-2004]

INTRODUCTION

We evaluated the organisation, management and outcome for patients operated on with gastric resection for cancer in Denmark in the period 1999-2003.

MATERIALS AND METHODS

Nationwide data based on the National Patient Registry and discharge information from hospital departments in the period 1 January 1999 to 31 December 2003 were analysed.

RESULTS

Thirty-seven departments performed 537 resections, with an average of 20 departments per year performing such operations. Five departments performed 57.2% of the operations, while 20 departments performed 10.2%. The average postoperative stay was 18 days and the hospital mortality rate was 8.2%, equally distributed with 7.8% for Billroth II resections and 8.5% for total gastrectomy.

DISCUSSION

The organization of gastric cancer surgery in Denmark in 1999-2003 was not optimal, with about 20 departments performing about 100 gastric resections annually, and with a mortality rate of slightly over 8% and an average hospital stay of 18 days. We propose that in future, gastric resections for cancer should be performed in a maximum of five departments nationwide.

[Formation of invaginational esophago-intestinal anastomosis in reconstructive extirpation of gastric stump]

In 1986-2003 yrs the interventions for cancer of the operated stomach were performed in 32 patients. Reconstructive extirpation of gastric stump (REGS) was conducted in 31 patient, subtotal reresection of gastric stump according to Roux--in 1. Esophago-intestinal anastomosis (EIA) was formed using modified method of K. N. Tsatsanidi. Postoperative mortality was 3.1%. In 1994-2003 yrs, while performing REGS and gastrectomy, EIA was formed in 529 patients. The rate of complicated healing of EIA 1.3%. The insufficiency of the EIA sutures after REGS performance was absent.

Endoscopic full-thickness resection with sutured closure in a porcine model

BACKGROUND

Some early gastric cancers might be advantageously staged and treated by full-thickness resection if secure methods for closing the defect were available. The aim of this study was to test the feasibility of full-thickness gastric resection.

METHODS

Full-thickness gastric resections were performed by using a ligating device without submucosal injection in survival studies in pigs (n = 8). The defects were closed by using new methods for suturing, locking, and cutting thread through a 2.8-mm accessory channel. Stitches (n = 2-4) were placed close to the target area before resection.

OBSERVATIONS

Full-thickness resections (n = 8) were performed. The pigs survived without incident for 21 to 28 days. Healing of the suture site was evident at follow-up endoscopy. Suture sites were water tight. The pull-out force with stitches by using this new sewing method was significantly higher than with endoscopic clips (20.3 N +/- 0.94 vs. 2.2 N +/- 0.42, p < 0.05).

CONCLUSIONS

Endoscopic full-thickness resection with sutured defect closure was feasible and appeared safe in these survival experiments.

Biologic and clinical variations of adenocarcinoma at the esophago-gastric junction: relevance of a topographic-anatomic subclassification

A topographic-anatomic subclassification of adenocarcinomas of the esophago-gastric junction (AEG) in distal esophageal adenocarcinoma (AEG Type I), true carcinoma of the cardia (AEG Type II), and subcardial gastric cancer (AEG Type III) was introduced in 1987 and is now increasingly accepted and used worldwide. Our experience with now more than 1,300 resected AEG tumors indicates that the subtypes differ markedly in terms of surgical epidemiology, histogenesis and histomorphologic tumor characteristics. While underlying specialized intestinal metaplasia can be found in basically all patients with AEG Type I tumors, this is uncommon in Type II tumors and virtually absent in Type III tumors. Stage distribution and overall long-term survival after surgical resection also shows marked differences between the AEG subtypes. Surgical treatment strategies based on tumor type allow a differentiated approach and result in survival rates superior to those reported with other approaches. The subclassification of AEG tumors thus provides a useful tool for the selection of the surgical procedure and allows a better comparison of treatment results.

D2 gastrectomy -- a safe operation in experienced hands

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.

[Multivariate prognostic analysis in gastric carcinoma patients after radical operation]

BACKGROUND & OBJECTIVE

Whether received radical operation is an important prognostic factor of gastric carcinoma. But the long-term efficacies of radical operation on different patients are not the same. This study was to investigate prognostic factors of gastric carcinoma.

METHODS

Clinical data of 405 patients with gastric carcinoma, received radical operation from Jan. 1985 to Dec. 1995 in Cancer Center of Sun Yat-sen University, were analyzed retrospectively. Life table method was used to analyze survival rate, Wilcoxon test was used for statistical comparison, and Cox regression model was used for multivariate analysis.

RESULTS

The 5-year overall survival rate was 43.4%. The 5-year survival rates of patients in pathologic TNM (pTNM) stage I, II, III, and IV were 75.6%, 58.7%, 28.0%, and 18.4%, respectively (P < 0.01). The 5- year survival rates of patients with tumor sizes of less than 2.0 cm, 2.0-3.9 cm, 4.0-5.9 cm, 6.0-7.9 cm, and no less than 8.0 cm were 82.0%, 57.4%, 43.7%, 38.7%, and 26.9%, respectively (P < 0.05). In addition, the 5-year survival rate was higher in patients with perioperative chemotherapy than in patients without perioperative chemotherapy (47.2% vs. 37.8%, P < 0.05). Univariate analysis showed that perioperative chemotherapy, Borrmann type, tumor size, pathologic type, and pTNM stage were prognostic factors of gastric carcinoma. Multivariate analysis showed that pTNM stage, tumor size, and perioperative chemotherapy were independent prognostic factors of gastric carcinoma.

CONCLUSIONS

pTNM stage, tumor size, and perioperative chemotherapy are the most significant factors influencing prognosis of gastric carcinoma patients after radical operation. Perioperative chemotherapy contributes to enhance survival rate of gastric carcinoma patients.

Survival after gastric adenocarcinoma resection: eighteen-year experience at a single institution

Gastric adenocarcinoma is the second leading cause of cancer death worldwide. In Western series, survival rates vary widely and are generally lower than those reported from Eastern series. We performed a retrospective analysis of cases operated on at the Johns Hopkins Hospital over the past 18 years and collected data on demographics, tumor characteristics, pathologic stage, treatment methods, complications, survival time, and other relevant factors. Survival according to stage of disease, Lauren tumor type, tumor location, time period, and administration of adjuvant therapy was analyzed, and results were compared with those of other Western series. During this period, 436 patients with gastric adenocarcinoma underwent resection. We have shown a statistically significant association between survival and margin status, stage of disease, and Lauren tumor type. Overall 5-year survival was 26%, and 5-year survival after R0 resection was 33%. No significant difference was detected between survival and tumor location, time period of treatment, or administration of adjuvant therapy. Analysis of various Western series reveals major differences between the cohorts under study, such as stage of disease, extent of resection, tumor type, and tumor location. Many of the reported differences among Western series may be due to cohort differences, such as stage of disease, extent of resection, tumor type, and tumor location.

Evaluation of POSSUM scoring system in patients with gastric cancer undergoing D2-gastrectomy

Background

Risk adjustment and stratification play an important role in quality assurance and in clinical research. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a patient risk prediction model based on 12 patient characteristics and 6 characteristics of the surgery performed. However, because the POSSUM was developed for quality assessment in general surgical units, its performance within specific subgroups still requires evaluation.

The aim of the present study was to assess the accuracy of POSSUM in predicting mortality and morbidity in patients with gastric cancer undergoing D2-gastrectomy.

Methods

137 patients with gastric cancer undergoing gastrectomy were included in this study. Detailed, standardized risk assessments and thorough documentation of the post-operative courses were performed prospectively, and the POSSUM scores were then calculated.

Results

The 30- and 90- day mortality rates were 3.6% (n = 5) and 5.8% (n = 8), respectively. 65.7% (n = 90) of patients had normal postoperative courses without major complications, 14.6% (n = 20) had moderate and 13.9% (n = 19) had severe complications. The number of mortalities predicted by the POSSUM-Mortality Risk Score (R1) was double the actual number of mortalities occurring in the median and high-risk groups, and was more than eight times the actual number of mortalities occurring in the low-risk group (R1 < 20%). However, the calculated R1 predicted rather well in terms of severe morbidity or post-operative death in each risk group: in predicted low risk patients the actual occurrence rate (AR) of severe morbidity or post-operative death was 14%, for predicted medium risk patients the AR was 23%, and for predicted high risk patients the AR was 50% (p < 0.05). The POSSUM-Morbidity Risk Score (R2) overestimated the risk of morbidity.

Conclusion

The POSSUM Score may be beneficial and can be used for assessment of the peri- and post-operative courses of patients with gastric carcinoma undergoing D2-gastrectomy. However, none of the scores examined here are useful for preoperative prediction of postoperative course.

Complications of gastrectomy with lymphadenectomy in gastric cancer

BACKGROUND

Currently, gastrectomy and extended lymphadenectomy (LN) is the treatment of choice for gastric cancer. Although a survival rate benefit of D2 LN compared to D1 LN has been shown, the D2 LN procedure is not fully employed, due to possible higher morbidity and mortality rates. These higher rates are being questioned in more recent series, in which D1 and D2 LN complication rates have been similar. The aim of this study was to analyze the immediate postoperative complications of patients submitted to total or subtotal gastrectomy with D1 or D2 LN (according to the Japanese guidelines for gastric cancer) at the Gastrointestinal Surgery Division of the Medical School of São Paulo University, between January 2001 and April 2003.

METHODS

One hundred consecutive patients were studied; 61 were men and 39, women. Total gastrectomy was performed in 52 patients (13 with D1 LN and 39 with D2 LN), and subtotal gastrectomy was performed in 48 (11 with D1 LN and 37 with D2 LN). Total or subtotal gastrectomy with D1 or D2 LN was performed according to the tumor extent and histological classification (Lauren's diffuse or intestinal type), considering the patient's general condition and the gastric cancer stage. Roux-en-Y reconstruction was performed in almost all patients.

RESULTS

No difference was observed regarding complications and mortality related to the extent of the gastrectomy. Although morbidity was higher in the D1 group, no significant difference was observed. Mortality was higher in the D1 group, and this was probably related to their poor surgical condition and more advanced tumors.

CONCLUSION

According to these results, it appears that total or subtotal gastrectomy with D2 LN in gastric cancer treatment, performed according to the Japanese guidelines, can be considered a safe procedure, with acceptable morbidity and mortality, when performed by a trained surgical team.

Surgical management of gastric stump cancer: a report of 37 cases

OBJECTIVE

To observe the clinicopathological characteristics of gastric stump cancer (GSC) and evaluate the benefits of radical surgery of GSC.

METHODS

The clinicopathological characteristics and postoperative survival time of 37 GSC patients who underwent surgery were investigated retrospectively. The survival time was compared according to the type of surgical operation (radical resection vs palliative operation). Twenty-one cases that received radical resection were analyzed based on the pTMN stage. Survival curves were traced by using Kaplan-Meier methods.

RESULTS

Most GSC (32/37) was detected in patients who had received Billroth II reconstruction after partial gastrectomy for benign gastric disease. The lesser curvature side and the suture line of anastomosis were the most frequent sites where GSC occurred (27/37). Differentiated adenocarcinoma was the dominant histopathological type (24/37). The postoperative 5-year survival rate of early stage GSC patients (n=9) was significantly higher than advanced stage GSC (n=12) (55.6% vs 16.5%, xL2=11.48, P<0.01). Five-year survival rate of 21 GSC patients with radical resection were 75% (3/4) for stage I, 60% (3/5) for stage II, 14.2% (1/7) for stage III, and 0% (0/5) for stage IV respectively. The median survival time of 21 GSC patients who underwent radical resection was longer than those undergoing palliative operation (43.0 m vs 13.0 m, x L2=36.31, P<0.01), the median survival time of stage IV patients with radical resection was 23.8 months.

CONCLUSIONS

Without remote metastasis, radical resection for GSC is possible, and is an effective way to improve the prognosis of GSC. Even in stage IV GSC, radical resection can still prolong the survival time. It is necessary for the patients with benign gastric diseases who received partial gastrectomy to carry out the endoscopy follow-up, especially in patients with Billroth II reconstruction procedure at 15-20 years.

Primary gastric lymphoma: a clinicopathologic study

BACKGROUND/AIMS

This study aims to define the clinicopathologic criteria of primary gastric lymphoma in view of MALT concept and to present the outcome after different treatment modalities.

METHODOLOGY

Seventy-six cases of primary gastric lymphoma treated between January 1980 and December 2001 were reviewed. All tissue specimens (endoscopic or surgically resected) were re-examined. Tumors were staged according to Ann Arbor staging system and the Musshoff modification (IE in 30.3%, IIE in 39.4% and IIIE in 30.3%). Sixty patients underwent gastrectomy (partial or total) with postoperative chemotherapy for 32 patients. Sixteen patients were treated by chemotherapy only. The mean follow-up period was 15 years (range, 6 months to 21 years).

RESULTS

Primary gastric lymphoma represented 69.1% of cases of gastrointestinal lymphoma and 16.2% of all gastric malignancy. The mean age was 45 years and male to female ratio was 2.3:1. Epigastric pain was the commonest symptom (in 88.2%). Ulcer-like lesions were the commonest (65.8%) and the most commonly involved site was the lower third (48.7%). The resectability rate was 80%. The operative mortality rate was 2.7%. Another 2 cases died after partial gastrectomy and chemotherapy. Four cases in the chemotherapy group (25%) died. Tumor recurrence occurred in 4 cases (out of 32) after gastrectomy and chemotherapy (12.5%), 2 of them died and 2 were cured by chemotherapy. The mean overall survival was 18.49 years, survival was 20.28 years after gastrectomy, 15.48 years after gastrectomy with chemotherapy and 5.76 years after chemotherapy (p=0.0056).

CONCLUSIONS

Primary gastric lymphoma is not an uncommon tumor. Gastritis-like lesions are rare. If the tumor is resectable, gastrectomy will provide the most accurate means of diagnosis, staging and locoregional control of the disease.

Do cancer centers designated by the National Cancer Institute have better surgical outcomes?

BACKGROUND

The National Cancer Institute (NCI) designates cancer centers as regional centers of excellence in research and patient care. Although these centers often advertise their superior outcomes, their relative performance has not been examined empirically. In the current study, the authors assessed whether patients at NCI cancer centers compared with patients at control hospitals had lower mortality rates after major cancer surgery.

METHODS

Using the national Medicare database (1994-1999), the authors assessed surgical mortality and late survival rates for 63,860 elderly patients undergoing resection for lung, esophageal, gastric, pancreatic, bladder, or colon carcinoma. For assessing performance, patients treated at the 51 NCI cancer centers were compared with patients from 51 control hospitals with the highest volumes for each procedure. Mortality rates (surgical and 5-year rates) were adjusted for patient characteristics and residual differences in procedure volume.

RESULTS

NCI cancer centers had lower adjusted surgical mortality rates than control hospitals for 4 of the 6 procedures, including colectomy (5.4% vs. 6.7%; P = 0.026), pulmonary resection (6.3% vs. 7.9%; P = 0.010), gastrectomy (8.0% vs. 12.2%; P < 0.001), and esophagectomy (7.9% vs. 10.9%; P = 0.027). Nonsignificant trends toward lower adjusted operative mortality rates at NCI cancer centers were also observed for cystectomy and pancreatic resection. Among patients surviving surgery, however, there were no important differences in subsequent 5-year mortality rates between NCI cancer centers and control hospitals for any of the procedures.

CONCLUSIONS

For many cancer procedures, patients undergoing surgery at NCI-designated cancer centers had lower surgical mortality rates than those treated at comparably high-volume hospitals, but similar long-term survival rates.

Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer

BACKGROUND

The appropriate extent of lymph node clearance during gastrectomy for cancer remains controversial.

METHODS

Medline, Embase, the Cochrane register and other databases were searched for studies reporting node dissection technique, 5 year survival and mortality after gastrectomy. Comparisons with systematic bias in treatment allocation and patients who received perioperative chemotherapy were excluded. Meta-analysis was performed separately for randomized and non-randomized comparisons.

RESULTS

Two randomized and two non-randomized comparisons of limited (D1) versus extended (D2) node dissection and 11 reports of one dissection type were analysed. For D2 the randomised trials showed no overall survival benefit (Risk ratio (RR) = 0.95, 95 per cent c.i. 0.83-1.09) and an increased postoperative mortality (RR = 2.23, c.i. 1.45-3.45), apparently related to pancreatico-splenectomy and surgical inexperience. A trend towards survival benefit for D2 was observed for T3+ tumours (RR = 0.68, c.i. 0.42-1.10). Non-randomized comparisons found no survival benefit for D2 (RR = 0.92, c.i. 0.83-1.02), but decreased postoperative mortality (RR = 0.65, c.i. 0.45-0.93). Nine observational studies of D2 reported better results than two studies of D1 surgery, but in very different settings.

CONCLUSIONS

Evidence for D2 dissection is inconclusive. No overall survival advantage has emerged, but some patients with intermediate stage disease may benefit. Excess operative mortality appears to be associated with pancreatico-splenectomy, low case volume and lack of specialist training.

Correlation between the current TNM staging and long-term survival after curative D1 lymphadenectomy for stomach cancer

BACKGROUND AND AIMS

This study aims to assess the tumour-related factors that influence long-term survival after curative gastrectomy with standard D1 lymphadenectomy for patients with stomach cancer.

PATIENTS AND METHODS

Patients who had undergone curative gastrectomy for carcinoma of the stomach at North Shore Hospital between 1990 and 2000 were identified from theatre records and the hospital database. Medical records were reviewed and included tumour location, type of operation, in-hospital mortality, gross morphology of tumour, histological type, and Helicobacter status; pathology slides were reviewed, and tumours were staged according to the new TNM staging. Patients were followed-up for 2-11 years. Length of survival was obtained for each patient from medical records or from family doctors.

RESULTS

R0 gastrectomy was performed on 70 patients; median survival was 23 months, and all patients with early gastric cancer are currently still alive. T stage, nodal stage and histological type correlated significantly with survival, but multivariate analysis showed that T stage is the most significant predictor. Five-year survival was 26%. Significant survival difference was seen between T2a and T2b.

CONCLUSION

Histological subtype, lymph node metastases and depth of invasion are factors that affect survival of patients with gastric cancer; however, depth of invasion is more important than other variables. Tumour location and type of gastrectomy has no effect on survival. The latest TNM classification (sixth edition) gives a better prognostication than the previous classification.

Characteristics of gastric carcinoma invading the muscularis propria

BACKGROUND

Although gastric carcinomas invading the muscularis propria (mp) are classified among advanced-stage cancers in Japan, postoperative survival has been reported to approximate that in early gastric carcinoma. Characteristics of gastric carcinomas invading the mp, therefore, were compared to carcinomas invading only the mucosa (m) or submucosa (sm), and to those invading the subserosa (ss) or serosa (se).

METHODS

We retrospectively compared clinicopathologic findings, prognosis, and cause of death in patients with gastric carcinoma invading mp to those showing the other levels of invasion.

RESULTS

Patients with carcinomas invading the mp had larger tumors and more frequent lymph node and hematogenous metastases than those with carcinomas invading only m or sm. Yet they had smaller tumors and less frequent lymph node or peritoneal metastasis than those with carcinomas invading ss or se. Postoperative survival with tumors invading the mp was intermediate between that with carcinoma invading only m or sm and that with subserosal or serosal invasion. Causes of death with tumors invading muscularis were similar to those with carcinomas invading only m or sm.

CONCLUSIONS

Characteristics of gastric carcinoma invading the mp are intermediate between those of early and advanced carcinoma.

Status of extended lymph node dissection: Locoregional control is the only way to survive gastric cancer

There are many factors that are of influence on gastric cancer treatment. The only way to survive is complete locoregional control. More extended dissections should lead to better outcome, but increased morbidity and mortality probably offset its long-term effect in survival in randomised studies. In this article the factors of influence on outcome of gastric cancer treatment such as the extent of lymph node dissection, splenectomy, pancreatectomy, age, volume and additional treatments are discussed. A literature review of these factors in relation to the latest results of the Dutch Gastric Cancer Trials are presented. If morbidity and mortality can be reduced there might be an advantage of extended lymph node dissection. Splenectomy and pancreatectomy should be performed only in case of direct in growth from the tumour into these organs. Centralisation of gastric cancer treatment should be achieved in order to improve results and to facilitate research. By refining selection criteria in the treatment of gastric cancer further improvements are to be expected.

Biological, histological, and clinical impact of preoperative IL-2 administration in radically operable gastric cancer patients

BACKGROUND AND OBJECTIVES

Surgery induces lymphocytopenia and this decrease of host defenses, related to interleukin-2 (IL-2) endogenous imbalance during postoperative period could promote the proliferation of possible micrometastases and the implantation of surgically disseminated tumor cells. Moreover, tumor infiltrating lymphocytes (TILs), activated by endogenous IL-2 release, are linked to prognosis in cancer patients. The aim of this randomized study is to assess the biological (peripheral blood cells count, related to the grade of immunosuppression), histological (TILs), and clinical (overall and disease-free survival) impact of preoperative low doses administration of IL-2 in patients with radically operable gastric cancer.

METHODS

This prospective study enrolled 69 consecutive patients with histologically proven gastric adenocarcinoma who underwent radical surgery from October 1999 to December 2002 (M/F 39/30; mean age 66; range 42-82) who underwent radical surgery from October 1999 to December 2000. Patients were randomized to be treated with surgery alone as controls (35 patients) or surgery plus preoperative treatment with recombinant human IL-2 (34 patients). We considered the total lymphocyte count and lymphocyte subset (CD4, CD4/CD8) during the preoperative period, before IL-2 administration, and on the 14th and 50th day, peritumoral stromal (fibrosis) reaction, neutrophils, lymphocytes, and eosinophils infiltration in tumor histology, and morbidity disease free and overall survival were evaluated.

RESULTS

Two groups were well matched for type of surgery and extent of disease. All the patients underwent radical surgery plus D2 lymphadenectomy. At baseline, there were no significant differences in total lymphocyte and lymphocyte subsets between groups. The control group showed a significant decrease of total lymphocytes, CD4 cells, and CD4/CD8 ratio at the 14th postoperative day relative to the baseline value. In the control group 65% of patients had a decrease of CD4 under 500 cells/mmc. Instead it has been observed in IL-2 group a significant increase over the control group values of total lymphocytes and CD4 cells (14th total lymphocytes and CD4: IL-2 vs. control P < 0.05). Moreover in this group only 15% patients had CD4 under 500 cells/mmc. This difference, in CD4 count, is significant even at the 50th postoperative day (P = 0.006). IL-2 group showed lower postoperative complications (2/34 vs. 11/35; P < 0.05), and higher lymphocyte/eosinophil infiltration into the tumor (P < 0.0002). Median follow-up was 26 months (range 10-48) and median overall and disease-free survivals were longer, even if not significantly, in the IL-2 group than in the control arm (P = 0.07 and P = 0.06 respectively).

CONCLUSIONS

This randomized study would suggest that a preoperative immunotherapy with IL-2 is a well-tolerated treatment able to prevent surgery-induced lymphocytopenia. IL-2 seems to neutralize the immunosuppression induced by operation and so to stimulate the host reaction against tumor tissue (lymphocytes/eosinophils infiltration). Furthermore IL-2 seems to have an impact on clinical course reducing morbidity of surgery and ameliorating overall and disease-free survival.

A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: early results

BACKGROUND

We conducted a prospective randomized trial to compare laparoscopy-assisted distal gastrectomy (LADG) including lymphadenectomy with open distal gastrectomy for the management of early gastric cancer (EGC).

METHODS

Forty-seven patients who had been diagnosed endoscopically with EGC were included in a study that ran from November 2001 to August 2003. With the aid of random number table, 23 patients were assigned to the open group (group O) and 24 patients were assigned to the LADG group (group L).

RESULTS

Estimated blood loss and transfusion amounts were similar in the two groups. The mean postoperative hospital stay and the duration of analgesic administration were shorter for group L but not significantly so. The mean number of harvested lymph nodes was 38.1 in the O group and 31.8 in the L group (p = 0.098). Postoperative pulmonary complications occurred more frequently in the O group (p = 0.043). At a median follow-up of 14 months, there has been no recurrence of disease in either group.

CONCLUSION

In terms of resulting in fewer pulmonary complications while maintaining the curability of EGC, LADG has a clear advantage over its open counterpart.

Evaluation of P-POSSUM and O-POSSUM scores in patients with gastric cancer undergoing resection

BACKGROUND/AIMS

The aim of this study was to evaluate the predictive accuracy of P-POSSUM and O-POSSUM models on patients undergoing elective gastric resection.

METHODOLOGY

P-POSSUM and O-POSSUM predictor equations for mortality were applied retrospectively to 126 patients who had undergone elective gastrectomy for cancer. Observed mortality rates were compared with rates predicted by P-POSSUM and O-POSSUM using the Hosmer-Lemeshow goodness-of-fit test. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic (ROC) curve analysis.

RESULTS

Overall fourteen deaths were observed. O-POSSUM predicted 15 deaths (chi2=14.61, p=0.13) and P-POSSUM predicted 20 deaths (chi2=25.41, p=0.002) using the Hosmer-Lemeshow test. ROC curves analysis revealed that O-POSSUM had better discriminatory power for mortality compared to P-POSSUM (area under curve=0.880, for O-POSSUM and area under curve=0.703 for P-POSSUM).

CONCLUSIONS

These data suggest that O-POSSUM predicts mortality more accurately than P-POSSUM in patients undergoing elective gastrectomy for cancer.

Therapeutic strategy for signet ring cell carcinoma of the stomach

BACKGROUND

Reports of clinicopathological characteristics and prognosis in patients with signet ring cell carcinoma (SRC) of the stomach are conflicting.

METHODS

A retrospective review was undertaken of 1450 patients with gastric cancer who had undergone gastrectomy. Of 1113 patients who underwent a curative gastrectomy, 174 had SRC (early, 120; advanced, 54) and 939 had other types of gastric carcinoma. Clinicopathological features, prognostic factors and surgical outcome in patients with SRC and non-SRC were compared.

RESULTS

In patients with early gastric cancer, age, histological type, and number and anatomical extent of lymph node metastases independently affected prognosis. Patients with SRC had a significantly better survival rate than those with non-SRC, although there was no difference in the extent or number of lymph node metastases. Mucosal tumours with a diameter of 40 mm or less and submucosal lesions with a diameter of 20 mm or less were not associated with lymph node metastasis. SRC in advanced disease was frequently poorly differentiated or scirrhous, but macroscopic appearance was not an independent prognostic factor.

CONCLUSION

Early SRC of the stomach is associated with a better prognosis than non-SRC. Conversely, in advanced gastric cancer histological type cannot be used to establish a definitive therapeutic strategy.

Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach

BACKGROUND

Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer.

OBJECTIVES

To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field.

SELECTION CRITERIA

Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons.

MAIN RESULTS

Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different.

REVIEWERS' CONCLUSIONS

D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Gastrectomy for gastric cancer: defining critical elements of patient selection and outcome assessment

In advanced gastric cancer, palliation of symptoms, rather than cure, is often the most appropriate goal of patient management. There are important differences among patients undergoing non-curative operations for gastric cancer. The literature to date is limited, in part, by imprecise use of the term palliative. In clinical decision-making, the potential benefits of proposed procedure must be balanced against the duration of hospitalization, treatment of complications, and requirements for additional palliation. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent inpatients receiving non-curative operations.

Prospective study of routine contrast radiology after total gastrectomy

BACKGROUND

The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation.

METHODS

Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy.

RESULTS

Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

CONCLUSION

There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer

Curative resection is the treatment of choice for potentially curable gastric cancer. Two major Western studies in the 1990s failed to show a benefit from D2 dissection. They showed extremely high postoperative mortality after D2 dissection, and were criticised for the potential inadequacy of the pretrial training in the new technique of D2 dissection, prior to the phase III studies being initiated. The inclusion of pancreatectomy and splenectomy in D2 dissection was associated with increased morbidity and mortality. Following these results, we started a phase II trial to evaluate the safety and efficacy of pancreas-preserving D2 dissection. The results of this trial regarding the safety of pancreas preserving D2 dissection were published in 1998. In this paper, we present the survival results of this phase II trial to confirm the rationale of carrying out a phase III study comparing D1 vs D2 dissection for curable gastric cancer. Italian patients with histologically proven gastric adenocarcinoma were registered in the Italian Gastric Cancer Study Group Multicenter trial. The study was carried out based on the General Rules of the Japanese Research Society for Gastric Cancer. A strict quality control system was achieved by a supervising surgeon of the reference centre who had stayed at the National Cancer Center Hospital, Tokyo, to learn the standard D2 gastrectomy and the postoperative management. The standard procedure entailed removal of the first and second tier lymph nodes. During total gastrectomy, the pancreas was preserved according to the Maruyama technique. Complete follow-up was available to death or 5 years in 100% of patients and the median follow-up time was 4.38 years. Out of 297 consecutive patients registered, 191 patients were enrolled in the study between May 1994 and December 1996. The overall morbidity rate was 20.9%. The postoperative in-hospital mortality was 3.1%. The overall 5-year survival rate among all eligible patients was 55%. Survival was strictly related to stage, depth of wall invasion, lymph node involvement and type of gastrectomy (distal vs total). Our results suggest a survival benefit for pancreas-preserving D2 dissection in Italian patients with gastric cancer if performed in experienced centres. A phase III trial among exclusively experienced centres is urgently needed.

Safe major abdominal operations: Hepatectomy, gastrectomy and pancreatoduodenectomy in elder patients

AIM: To evaluate the impact of advanced age on outcome after hepatectomy, gastrectomy and pancreatoduodenectomy.

METHODS: Two hundreds and eleven patients undergone hepatectomy, gastrectomy and pancreatoduodenectomy from January 1998 to September 2002 were analyzed retrospectively. Clinicopathologic features and operative outcome of 83 patients aged 65 years or more were compared with that in 128 younger patients aged less than 65 years.

RESULTS: The nutritional state, such as pre-operation level of serum albumin and hemoglobin in the older patients was poorer than that in the younger patients. The older patients had higher comorbidities than the younger patients (48.2% vs 15.6%). No significant difference was observed in perioperative mortality, and complication rate between the older and younger patients (2.4% vs 1.6% and 22.9% vs 20.3%, respectively). Multivariate analysis demonstrated that pancreatoduodenectomy, hepatectomy with resection of more than 2 segments and comorbidities were independent predictors of postoperative complication, whereas age was not (P = 0.3172).

CONCLUSION: It is safe for patients aged 65 years or more to undergo hepatic, pancreatic and gastric resection if great care is taken during perioperative period.

[Postoperative morbidity and in-hospital mortality of gastrectomy due to gastric adenocarcinoma: a report of 50 years]

OBJECTIVE

Determine the postoperative morbidity and in-hospital mortality of gastrectomy due to gastric cancer.

METHOD

The study involved the review of the clinical records of all patients with histologically confirmed diagnostic of gastric adenocarcinoma, which underwent a gastrectomy at the Peruvian Institute of Neoplastic Diseases between January 1950 and December 1999. During that period, 2,033 gastrectomies were performed, 503 of which were total gastrectomies and 1,447 were distal subtotal gastrectomies. Postoperative morbidity of total and distal subtotal gastrectomy dropped from 23.7% and 14.3% during the 1950 decade, to 19.8% and 7.4% during the 1990 decade, respectively, while the in-hospital mortality of total and subtotal gastrectomy dropped from 28.9% and 19.4% during the 50s to 4.4% and 2.2% during the 90's. The most common complications were the esophagojejunal, gastrojejunal and duodenal fistulas, respiratory infections, intra-abdominal abscesses, pancreatic fistula, early intestinal obstruction, hemorrhage from the anastomosis site and surgical site infection.

RESULTS

Multivariate logistics regression analysis showed that the risk factors for in-hospital mortality of total gastrectomy were hypoalbuminemia, intraoperative blood transfusion and re-resection (OR: 2.4, 5.9 and 1.7, respectively). For distal subtotal gastrectomy, the risk factors for in-hospital mortality were hypoalbuminemia, intraoperative blood transfusion, splenectomy and re-resection (OR: 2.6, 2.46, 2.42 and 6.3, respectively).

CONCLUSIONS

Based on our results, the in-hospital mortality risk depends on the postoperative variables (hypoalbuminemia, intraoperative blood transfusion, splenectomy and re-resection) more than on the pre-operative variables, beyond the surgeon's control (age, sex, clinical stage, etc.).