Morbidity and mortality according to age following gastrectomy for gastric cancer

Survival benefits of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with locally advanced gastric cancer: insights from a population-based study

BACKGROUND AND AIMS

Postoperative adjuvant chemotherapy in older adults aged ≥ 80 years with locally advanced gastric cancer (LAGC) remains debated owing to concerns over treatment tolerance and limited data. We aimed to assess the effectiveness of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with LAGC using data from the Surveillance, Epidemiology, and End Results database.

METHODS AND RESULTS

A total of 2395 patients with LAGC aged ≥ 80 years who underwent radical surgery between 2004 and 2015 were identified. Propensity score matching (1:1) was applied to pair 422 patients receiving adjuvant chemotherapy with 1973 patients who underwent surgery alone. Multivariate logistic regression identified independent predictors of adjuvant chemotherapy, including the period from 2012-2015, pN1-2 and pN3 stages, and radiation therapy. Conversely, age ≥ 85 years predicted decreased chemotherapy use. Cancer-specific survival (CSS) and overall survival (OS) were compared using multivariate Cox analysis, showing significantly longer OS and CSS in the adjuvant chemotherapy group, before and after matching. Subgroup analysis revealed that patients aged 80-84 years and those with N + stages benefited most from adjuvant chemotherapy, whereas patients aged ≥ 90 years did not show significant benefit.

CONCLUSION

Postoperative adjuvant chemotherapy should be considered for patients aged ≥ 80 years with LAGC, especially those with lymph node involvement, as it offers significant survival benefits. However, as age approaches 90 years, the benefits of adjuvant chemotherapy may diminish, warranting more cautious application.

Preoperative predictors of postoperative complications after gastrectomy for gastric cancer, a population-based study in Finland

INTRODUCTION

International studies on preoperative risk factors of postoperative complications after gastrectomy for gastric cancer are few, and studies done in a population-based setting or using standardized definitions are lacking. Gastrectomy for gastric cancer is characterized by high complication rates and mortality, and identifying the risk factors for postoperative complications and mortality enables to improve the postoperative outcomes.

MATERIALS AND METHODS

This nationwide population-based cohort study is based on the Finnish National Esophago-Gastric Cancer Cohort, and it included all patients undergoing gastric cancer surgery in Finland during 2005-2016 aged 18 years or older. The Esophagectomy Complications Consensus Group's (ECCG) standardized list of complications was used for describing different types of postoperative outcomes.

RESULTS

This study analyzed a total of 1993 patients. The results suggested that of potential risk factors, higher ASA-class, and advanced tumor stage increased the risk of major postoperative complications after gastrectomy for gastric cancer, whereas age ≥70 years and distal tumor location may be protective factors. The results suggested that older age, higher ASA-class, comorbidity, and advanced tumor stage were risk factors for 90-day mortality. Older age seemed to be a risk factor for 90-day mortality, whereas it seemed to protect from major postoperative complications and 90-day reoperations.

CONCLUSIONS

Higher ASA-class, and advanced tumor stage were risk factors for major complications after gastrectomy for gastric cancer, while older age and distal tumor location seemed to be protective factors.

Risk factors for serious postoperative complications following gastrectomy in super-elderly patients ≥85-years-old with gastric cancer: A National Clinical Database study in Japan

Aim

This study aimed to evaluate the technical safety and feasibility of gastrectomy for super-elderly patients ≥85-y-old with gastric cancer and to clarify the risk factors for serious postoperative complications in these patients.

Methods

Between 2017 and 2020, 10,203 patients who underwent distal gastrectomy (DG) and 2580 patients who underwent total gastrectomy (TG) were reviewed from the Japanese National Clinical Database. All possible preoperative factors were used to explore the risk factors for serious postoperative complications in the super-elderly patients with gastric cancer.

Results

For DG, the operative mortality rate was 1.6% (162 patients), and the rate of serious postoperative complications was 7.8% (796 patients). Similarly, the mortality rate was 2.6% (67 patients), and the rate of serious complications was 11.3% (292 patients) for TG. Based on multivariate analysis, body mass index (≥25 kg/m2), activities of daily living (ADL) (partially dependent), ASA-PS (Grade ≥3), dyspnea, ascites, history of cerebrovascular disease, serum albumin (<4 g/dL), and creatinine (>1.2 mg/dL) in DG, and ADL (partially dependent), ASA-PS (Grade ≥3), previous percutaneous coronary intervention, dialysis, WBC (>9000 μL), and AST (>35 IU/L) in TG were strong risk factors for serious postoperative complications.

Conclusions

The study findings suggest that gastrectomy for super-elderly gastric cancer patients is relatively safe and feasible. Surgeons need to pay special attention to physical status and past medical history than tumor factors for preventing serious postoperative complications in super-elderly gastric cancer patients.

Impact of splenectomy on long-term outcomes after gastrectomy for gastric cancer: a population-based study

BACKGROUND

No national studies comparing long-term survival after total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation exist. This study aimed to examine the 5-year overall survival (OS) of patients with gastric adenocarcinoma who underwent total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation in a population-based nationwide setting.

METHODS

This study included all patients undergoing total or partial gastrectomy with splenectomy or spleen preservation for gastric adenocarcinoma in Finland from 2005 to 2016, with follow-up until December 31, 2019. A total of 2196 patients with gastric cancer diagnosis and total or partial gastrectomy were identified in the registries. Of these patients, 2118 were applicable for this study. Cox proportional hazard models provided hazard ratios (HRs) with 95% CIs of 5-year OS. The results were adjusted for age, sex, year of operation, comorbidities, tumor location, pathologic stage, and neoadjuvant therapy.

RESULTS

The observed 5-year OS rates were 38.7% in patients with no or minor spleen injury, 39.7% in patients with splenectomy due to injury, and 30.8% in patients with splenectomy due to oncologic reasons (P = .032). Patients who underwent R0 gastrectomy with splenectomy due to oncologic reasons had higher 5-year mortality (the adjusted model HR, 1.26; 95% CI, 1.01-1.56) than patients who underwent spleen preservation.

CONCLUSION

The OS was worst in patients who underwent gastrectomy with splenectomy due to oncologic reasons, highlighting the poor prognosis in patients with advanced gastric cancer. Splenectomy due to injury does not compromise the prognosis.

Risk factor analysis and nomogram construction of postoperative complications for patients with locally advanced gastric cancer who received neoadjuvant immunotherapy and chemotherapy

Introduction

The combination of neoadjuvant immunotherapy and chemotherapy (NICT) has become a common treatment regimen for locally advanced gastric cancer (LAGC). However, the safety and efficacy of radical gastrectomy following NICT (NICT-G) remain controversial. This study aimed to analyze the risk factors influencing postoperative complications (POCs) after NICT-G. Additionally, it aimed to construct a nomogram to provide a clinical reference for predicting POCs.

Methods

This study included 177 patients who received NICT-G at the Chinese PLA General Hospital First Medical Center from January 2020 to January 2024. Univariable and multivariable logistic regression models were used to evaluate the risk factors influencing POCs, and a nomogram model was constructed. To evaluate the discrimination and accuracy of the nomogram model, the area under the receiver operating characteristic curve (AUC) and the calibration curve were measured.

Results

In 177 patients who received NICT-G, the pathological complete response and major pathological response rates were 15.8% and 45.2%, respectively, whereas the rates of the overall and severe treatment-related adverse events were 71.8% and 15.8%, respectively. In addition, 43 (24.3%) patients developed overall POCs (Clavien-Dindo classification ≥ II). Univariable and multivariable logistic analyses showed that age ≥70 years, greater estimated blood loss, platelet/lymphocyte ratio (PLR) ≤196, neutrophil/lymphocyte ratio (NLR) >1.33, non-R0 resection, and body mass index (BMI) < 18.5 kg/m2 were independent risk factors for overall POCs (p < 0.05). The nomogram model developed using the abovementioned variables showed that the AUC (95% confidence interval [CI]) was 0.808 (95% CI): 0.731-0.885 in predicting the POC risk. The calibration curves showed that the prediction curve of the nomogram was a good fit for the actual POCs (Hosmer-Lemeshow test: χ2 = 5.76, P = 0.451).

Conclusion

The independent risk factors for overall POCs in the NICT-G were age ≥ 70 years, greater estimated blood loss, PLR ≤ 196, NLR > 1.33, non-R0 resection, and BMI < 18.5 kg/m2. The nomogram model developed based on the abovementioned indicators showed better accuracy in predicting the POC risk.

Clinical calculator based on CT and clinicopathologic characteristics predicts short-term prognosis following resection of microsatellite-stabilized diffuse gastric cancer

PURPOSE

Although microsatellite stability/Epithelial-mesenchymal transition (MSS/EMT) subtypes have been reported in multiple cancer prognosis studies, strong confounding factors between MSS/EMT (usually with Lauren's diffuse phenotype) and diffuse gastric cancer (GC) may obscure the independent prognostic value of diffuse GC. Additionally, recent studies suggest a strong correlation between mural stratification based on CT and diffuse GC. This study aims to investigate potential prognostic factors of MSS diffuse GC using mural stratification and to develop a risk assessment model.

METHODS

This retrospective study included 131 patients with MSS diffuse GC who underwent radical surgery. Univariate and multivariate Cox proportional hazards regression analysis was used to identify model predictors and construct a nomogram for overall survival (OS) and recurrence-free survival (RFS) risks. The model's performance was evaluated using ROC, accuracy, and C-index. Internal validation of the model was conducted using the bootstrap resampling method.

RESULTS

Among 131 cases, 60 cases (45.8%) exhibited grade 2 mural stratification, which correlated with a poorer tumor prognosis and a more invasive phenotype. Furthermore, a nomogram for predicting OS and RFS prognosis was established based on multivariate results (age, extranodal invasion, mural stratification, and/or P53). The nomogram demonstrated excellent performance, with an AUC of 0.859 (95% CI 0.794-0.924) for OS and 0.859 (95% CI 0.789-0.929) for RFS. Internal validation using 1000 bootstrap samples yielded AUC values of 0.845 and 0.846 for OS and RFS, respectively.

CONCLUSION

Grade 2 mural stratification based on CT imaging revealed a more aggressive invasive phenotype, characterized by increased LN metastasis, higher rates of peritoneal metastasis, and a poorer short-term prognosis. Furthermore, the CT phenotype-based nomogram demonstrates favorable discrimination and calibration, enabling convenient individual short-term prognostic evaluation following resection of MSS diffuse GC.

Short-term efficacy of additional laparoscopic-assisted radical gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To investigate short-term efficacy of direct laparoscopic-assisted radical gastrectomy (LAG) versus non-curative endoscopic submucosal dissection (ESD) plus additional LAG for early gastric cancer.

MATERIALS AND METHODS

286 patients were retrospectively assigned into two groups: direct LAG group (n = 255) and additional LAG (ESD plus LAG, n = 31) group. A 1:2 propensity score matching was performed to equalize relevant confounding factors between two groups for analysis.

RESULTS

Ninety-three patients were successfully matched, including 62 in the direct LAG group and 31 in the additional LAG group. A significant (P = 0.013) difference existed in the drainage removal time between the additional LAG and direct LAG group (7 d vs. 6 d). Age, sex, tumor location and surgical approach were significantly (P < 0.05) associated with complications, with age ≥ 60 years (P = 0.002) and total gastrectomy (P = 0.011) as significant independent risk factors. A significant (P = 0.023) difference existed in the surgical time between the early and late groups (193.3 ± 37.6 min vs. 165.5 ± 25.1 min).

CONCLUSION

Additional LAG (D1 + lymphadenectomy) after ESD may be safe and effective even though non-curative ESD may prolong the drainage removal time and increase the difficulty of surgery.

A Novel Intraoperative Leak Test Procedure (GAM Procedure) to Prevent Postoperative Anastomotic Leakage in Gastric Cancer Patients Who Underwent Gastrectomy

BACKGROUND

Anastomotic leakage following a radical gastrectomy is a serious complication of gastric cancer and esophagogastric junction cancer. The benefit of intraoperative leak testing for the prevention of postoperative anastomotic leakage has been controversial. We introduce a new procedure, which combines the techniques of gastroscopy, air, and methylene blue (GAM) for intraoperative leakage testing. Our objective was to evaluate the efficacy and safety of the GAM procedure for intraoperative leak testing and to compare the surgical complications of gastric cancer patients who underwent gastrectomy with and without intraoperative leak testing using the GAM procedure.

MATERIALS AND METHODS

A total of 210 patients who underwent radical gastrectomy for gastric cancer were included. Patients were divided into 2 groups: the intraoperative leak testing group using the GAM procedure (IOLT), and the group for which no intraoperative leak testing was done (NIOLT). Clinical and pathologic characteristics, the incidence of postoperative anastomotic leakage, and other surgical complications were compared between the 2 groups.

RESULTS

There were 82 patients in the IOLT group and 82 patients in the NIOLT group after propensity score matching. In the IOLT group, 4 (4.9%) patients were found to have anastomotic discontinuity during the operation; we repaired these anastomotic discontinuities intraoperatively. The incidence of postoperative anastomotic leakage was higher in the NIOLT group compared with the IOLT group, 6 (7.3%) versus 0 (0%), respectively ( P =0.01). The average time of the GAM procedure was 4.99±1.75 minutes. The surgical time was prolonged by 30 minutes in the IOLT group compared with the NIOLT group, 302.2±79.9 versus 272.1±85.2, respectively ( P =0.02). The length of hospital stay, 15.80±4.55 versus 17.00±6.20 ( P =0.16) was reduced in the IOLT group compared with the NIOLT group. The logistic regression model suggested that IOLT, sex, age, Eastern Cooperative Oncology Group, cT stage, tumor diameter, pT stage, pN stage, and Lauren classification were not risk factors for postoperative complication.

CONCLUSIONS

The GAM procedure of intraoperative leakage testing can effectively reduce the incidence of postoperative anastomotic leakage in gastric cancer patients undergoing gastrectomy.

The predictive effect of immune therapy and chemotherapy under T cell-related gene prognostic index for Gastric cancer

Background: Gastric cancer (GC) is one of the most common malignancies in the human digestive tract. CD4+T cells can eliminate tumor cells directly through the mechanism of cytolysis, they can also indirectly attack tumor cells by regulating the tumor TME. A prognostic model of CD4+T cells is urgently needed to improve treatment strategies and explore the specifics of this interaction between CD4+T cells and gastric cancer cells. Methods: The detailed data of GC samples were downloaded from the Cancer Genome Atlas (TCGA), GSE66229, and GSE84437 datasets. CD4+ T cell-related genes were identified to construct a risk-score model by using the Cox regression method and validated with the Gene Expression Omnibus (GEO) dataset. In addition, postoperative pathological tissues of 139 gastric cancer patients were randomly selected for immunohistochemical staining, and their prognostic information were collected for external verification. Immune and molecular characteristics of these samples and their predictive efficacy in immunotherapy and chemotherapy were analysed. Results: The training set and validation set had consistent results, with GC patients of high PROC and SERPINE1 expression having poorer prognosis. In order to improve their clinical application value, we constructed a risk scoring model and established a high-precision nomogram. Low-risk patients had a better overall survival (OS) than high-risk patients, consistent with the results from the GEO cohort. Furthermore, the risk-score model can predict infiltration of immune cells in the tumor microenvironment of GC, as well as the response of immunotherapy. Correlations between the abundance of immune cells with PROC and SERPINE1 genes were shown in the prognostic model according to the training cohort. Finally, sensitive drugs were identified for patients in different risk subgroup. Conclusion: The risk model not only provides a basis for better prognosis in GC patients, but also is a potential prognostic indicator to distinguish the molecular and immune characteristics of the tumor, and its response to immune checkpoint inhibitor (ICI) therapy and chemotherapy.

Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer.

METHODS

Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year.

CONCLUSIONS

The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.

The impact of age on long-term survival following gastrectomy for gastric cancer

INTRODUCTION

Gastrectomy remains the primary curative treatment modality for patients with gastric cancer. Concerns exist about offering surgery with a high associated morbidity and mortality to elderly patients. The study aimed to evaluate the long-term survival of patients with gastric cancer who underwent gastrectomy comparing patients aged <70 years with patients aged ≥70 years.

METHODS

Consecutive patients who underwent gastrectomy for adenocarcinoma with curative intent between January 2000 and December 2017 at a single centre were included. Patients were stratified by age with a cut-off of 70 years used to create two cohorts. Log rank test was used to compare overall survival and Cox multivariable regression used to identify predictors of long-term survival.

RESULTS

During the study period, 959 patients underwent gastrectomy, 520 of whom (54%) were aged ≥70 years. Those aged <70 years had significantly lower American Society of Anesthesiologists grades (p<0.001) and were more likely to receive neoadjuvant chemotherapy (39% vs 21%; p<0.001). Overall complication rate (p=0.001) and 30-day postoperative mortality (p=0.007) were lower in those aged <70 years. Long-term survival (median 54 vs 73 months; p<0.001) was also favourable in the younger cohort. Following adjustment for confounding variables, age ≥70 years remained a predictor of poorer long-term survival following gastrectomy (hazard ratio 1.35, 95% confidence interval 1.09, 1.67; p=0.006).

CONCLUSIONS

Low postoperative mortality and good long-term survival were demonstrated for both age groups following gastrectomy. Age ≥70 years was, however, associated with poorer outcomes. This should be regarded as important factor when counselling patients regarding treatment options.

Gastric adenocarcinoma with high‑level microsatellite instability: A case report

Gastric cancer (GC) ranks fifth on the list of the most common malignancies worldwide. In Peru, gastric neoplasms are considered the second leading cause of mortality among males. Among the molecular subgroups of GC, microsatellite instability presents a favorable prognosis due to its hypermutated phenotype, which activates immunosurveillance. The present study describes the case of a 75-year-old patient, who was admitted in the hospital with a history of upper gastrointestinal bleeding and recurrent hospital admission, due to severe anemia. The patient presented with pale skin, normal vital functions, slight swelling of the lower extremities, and abdominal distention and bloating upon a physical examination. An endoscopic examination revealed an infiltrating circular ulcerated lesion. The histopathological analysis identified a moderately differentiated intestinal-type adenocarcinoma with pathological stage T3N0M0. Tumor genomic profiling demonstrated alterations in 15 different genes with a tumor mutational burden of 28 mutations/Mb. Finally, the patient underwent a partial gastrectomy without pre-operative chemotherapy. After 4 days, the patient presented with post-operative complications for which he was re-operated on. The patient did not survive. To the best of our knowledge, in the present case, pernicious anemia was an early sign of GC and a gastroscopy had to be performed. Furthermore, MutS homolog 3 alterations probably conditioned the presence of multiple frame-shift mutations.

The landscape of enhancer RNA identify prognosis-related molecular subtypes in gastric cancer

BACKGROUND

Enhancer RNAs (eRNAs), the transcriptional products of active enhancers, are of great significance in the initial progression of cancers. However, the biological function and bioinformatics profiles of eRNA in gastric cancer remains largely enigmatic.

METHODS

Firstly, STAD were clustered into three subtypes with the data of eRNA expression from TCeA. Then we explored the difference of the tumor immune microenvironment, transcription levels, and transcription regulation among the three clusters. Finally, samples collected from 12 patients diagnosed with STAD were used to conduct qRT-PCR, verifying the conclusion based on network database.

RESULTS

The three clusters were detected to have different tumor microenvironments: Cluster A has an immune "cold" microenvironment. While cluster B features as more infiltration of immune cells, accompanied with higher expression of immune checkpoints such as PDCD1, LAG3, and TIGIT. Besides, Cluster C shows a higher stromal feature with B lineage, neutrophils, and fibroblasts. Further analyses indicated that CpG island methylation level of Cluster B is different from the other two clusters. Meanwhile, Cluster A and B showed significant enrichment of TP53 and KRAS mutation respectively while Cluster C has higher tumor mutation burden (TMB) and microsatellite instability (MSI). With the elaboration of transcriptional regulation of epigenetic clustering, we detected that Cluster A enriched in epithelial phenotype pathways. Cluster B enriched in cell-cell adhesion. Cluster C enriched in fibroblast proliferation. The clinical cohort show that Cluster B patients have lower interstitial cell characteristics and CAF infiltration.

CONCLUSION

We identified three unique epigenetic clusters of STAD through the differential activation of super-enhancers, and identified Cluster B with a higher immune infiltrating and a better prognosis, which provides a novel understanding of eRNAs and potential clinical applicability of eRNA-based molecular subtypes in gastric cancer.

Short-term postoperative outcomes of gastric adenocarcinoma patients treated with curative intent in low-volume centers

BACKGROUND

Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed.

METHODS

Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry.

RESULTS

Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality.

CONCLUSIONS

Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.

Volatile anesthesia versus propofol-based total intravenous anesthesia: A retrospective analysis of charts of patients who underwent elective digestive tract cancer curative surgeries

The surgical stress responses, surgeries, and anesthetics used during surgeries have effects on post-surgery complications and metastasis. Volatile and/or intravenous anesthetics are generally used for cancer curative surgeries. Therefore, appropriate selection of anesthetics should be considered for better clinical outcomes. The objectives of the study were to compare postoperative complications, the overall survival, and recurrence-free survival of patients who had received volatile anesthesia against those of patients who had received propofol-based total intravenous anesthesia for digestive tract cancer curative surgeries. Patients had received propofol-based total intravenous anesthesia (PA cohort, n = 120) or volatile anesthesia (VA cohort, n = 185) for elective digestive tract cancer curative surgeries. Patients with age > 50 years (P = .0399), body mass index ≥ 25 kg/m2 (P = .0423), cancer stage III (P = .0041), and cancer stage IV (P = .0189) were operated through volatile anesthesia. Females (P = .0346), disable patients (P = .0479), patients with Charlson Comorbidity Index 2 (P = .0449), patients with cancer stage 0 or I (P = .0141), and patients with cancer stage II (P = .0289) were operated through propofol-based total intravenous anesthesia. Postoperative complication(s) between patients of both cohorts were statistically same (P = .9217). After 3-years of the follow-up period, a total of 81 (44%) patients from the VA cohort and 63 (52%) patients from the PA cohort survived irrespective of any kind of disease(s) (P = .9918). Also, a total of 53 (29%) patients from the VA cohort and 42 (35%) patients from the PA cohort survived without progression of cancer (P = .9981) after 3-years. Age > 50 years (P = 0.0491), Charlson Comorbidity Index ≥ 3 (P = 0.0481), and cancer stage > II (P = .0412) were independent parameters for death of patients suffering from digestive tract cancer due to any reason(s) during 3-years of the follow-up period after surgeries. The selection of anesthetic agents for cancer curative surgeries does not affect survival during 3-years of follow-up and postoperative complication(s) of patients suffering from digestive tract cancer (Level of Evidence: III; Technical Efficacy Stage: 4).

Body Composition Is a Predictor for Postoperative Complications After Gastrectomy for Gastric Cancer: a Prospective Side Study of the LOGICA Trial

PURPOSE

There is a lack of prospective studies evaluating the effects of body composition on postoperative complications after gastrectomy in a Western population with predominantly advanced gastric cancer.

METHODS

This is a prospective side study of the LOGICA trial, a multicenter randomized trial on laparoscopic versus open gastrectomy for gastric cancer. Trial patients who received preoperative chemotherapy followed by gastrectomy with an available preoperative restaging abdominal computed tomography (CT) scan were included. The CT scan was used to calculate the mass (M) and radiation attenuation (RA) of skeletal muscle (SM), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). These variables were expressed as Z-scores, depicting how many standard deviations each patient's CT value differs from the sex-specific study sample mean. Primary outcome was the association of each Z-score with the occurrence of a major postoperative complication (Clavien-Dindo grade ≥ 3b).

RESULTS

From 2015 to 2018, a total of 112 patients were included. A major postoperative complication occurred in 9 patients (8%). A high SM-M Z-score was associated with a lower risk of major postoperative complications (RR 0.47, 95% CI 0.28-0.78, p = 0.004). Furthermore, high VAT-RA Z-scores and SAT-RA Z-scores were associated with a higher risk of major postoperative complications (RR 2.82, 95% CI 1.52-5.23, p = 0.001 and RR 1.95, 95% CI 1.14-3.34, p = 0.015, respectively). VAT-M, SAT-M, and SM-RA Z-scores showed no significant associations.

CONCLUSION

Preoperative low skeletal muscle mass and high visceral and subcutaneous adipose tissue radiation attenuation (indicating fat depleted of triglycerides) were associated with a higher risk of developing a major postoperative complication in patients treated with preoperative chemotherapy followed by gastrectomy.

Associations of radiological features of adipose tissues with postoperative complications and overall survival of gastric cancer patients

OBJECTIVES

To evaluate the associations of the radiological features of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) with the postoperative complications and overall survival (OS) of patients undergoing laparoscopic radical gastrectomy for gastric cancer.

METHODS

One hundred forty-two patients underwent laparoscopic radical gastrectomy for gastric cancer from February 2013 to May 2016. The radiological features of SAT and VAT were studied by preoperative computed tomography, and the relationships between the parameters of adipose tissues and the intraoperative and postoperative conditions and OS rate of patients were evaluated.

RESULTS

A positive linear correlation was found between VAT area and operation duration, and a negative linear correlation was found between VAT density and intraoperative blood loss (p < 0.05 in both). VAT area was an independent risk factor for postoperative complications. VAT area and VAT density were independent risk factors for OS in gastric cancer.

CONCLUSIONS

A high VAT area was an independent risk factor for postoperative complications of gastric cancer, whereas a low VAT area and high VAT density were independent risk factors for poor prognosis in terms of OS in gastric cancer.

KEY POINTS

• A large visceral adipose tissue (VAT) area is an unfavourable factor affecting the outcomes of radical gastrectomy for gastric cancer. • Low VAT density may be more likely to cause intraoperative bleeding. • VAT area and VAT density were independent risk factors for the OS of patients with gastric cancer.

Surgical and oncological outcomes of D1 versus D2 gastrectomy among elderly patients treated for gastric cancer

INTRODUCTION

Gastrectomy with D2 lymphadenectomy is considered standard treatment in gastric cancer (GC). Among Western patients, morbidity and mortality seem to increase in D2 relative to D1 lymphadenectomy. As elderly patients with co-morbidities are more prone to possible complications, it is unclear whether they benefit from D2 lymphadenectomy. This study aims to compare the short- and long-term results of D1 and D2 lymphadenectomy in elderly patients undergoing gastrectomy for GC.

METHODS

All elderly (⩾75 years) patients undergoing gastrectomy with curative intent for GC during 2000-2015 were included and grouped according to the level of lymph node dissection into the D1 or D2 group. Short-term surgical outcome included the Comprehensive Complication Index (CCI) and 30-day mortality. Long-term outcomes comprised overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Cox regression was used in multivariable analyses.

RESULTS

In total, 99 elderly patients were included in the study (51 in D1 group, 48 in D2 group). The median follow-up was 32.5 months. Patients in the D1 group were older and had a higher American Society of Anesthesiologist (ASA) score. Both groups had similar burden of postoperative complications (CCI 20.9 versus 22.6, p = 0.26, respectively) and 90-day mortality (2% for both groups). The OS, DSS, and DFS were similar between groups. Multivariable analysis adjusted for potential confounders detected no difference in the survival between the D1 and D2 groups.

CONCLUSIONS

Gastrectomy with D2 lymphadenectomy can be performed with low postoperative morbidity and mortality suggesting its use also in the elderly. Long-term outcomes seem similar but need further studies.

Increasing utilization of endoscopic local excision for early-stage gastric cancers in the United States

BACKGROUND

The Japanese Gastric Cancer Association provided updated criteria for endoscopic local excision of early-stage gastric cancer in 2018. The purpose of this study was to evaluate utilization patterns for endoscopic local excision in the United States for resectable gastric adenocarcinoma.

METHODS

Patients with resectable gastric adenocarcinoma were identified from the National Cancer Database between 2010 and 2017. Patients were classified into strict appropriate criteria, expanded criteria, and inappropriate based on the Japanese Gastric Cancer Association guidelines. Factors associated with endoscopic local excision were identified using univariate and logistic multivariate regression.

RESULTS

Within the National Cancer Database, 46,334 patients were stratified into strict appropriate criteria (n = 1,405), expanded criteria (n = 727), and inappropriate (n = 43,675). Annual cases of local excision increased by 76.9% over the study period, from 273 in 2010 to 483 in 2017. Among patients who underwent local excision, 10.1% were classified as strict appropriate criteria, 1.6% were classified as expanded criteria, and 84.5% were classified as inappropriate. Among inappropriate patients, factors associated with endoscopic local excision were: more recent year of diagnosis, increasing age, female sex, tumor located in the cardia, smaller size, low-grade, absence of lymphovascular invasion, and treatment at an academic facility.

CONCLUSION

The use of endoscopic local excision for gastric cancer has nearly doubled since 2010. However, most patients do not satisfy consensus criteria for endoscopic therapy.

Nomogram to Predict Intensive Care Following Gastrectomy for Gastric Cancer: A Useful Clinical Tool to Guide the Decision-Making of Intensive Care Unit Admission

BACKGROUND

We aimed to generate and validate a nomogram to predict patients most likely to require intensive care unit (ICU) admission following gastric cancer surgery to improve postoperative outcomes and optimize the allocation of medical resources.

METHODS

We retrospectively analyzed 3,468 patients who underwent gastrectomy for gastric cancer from January 2009 to June 2018. Here, 70.0% of the patients were randomly assigned to the training cohort, and 30.0% were assigned to the validation cohort. Least absolute shrinkage and selection operator (LASSO) method was performed to screen out risk factors for ICU-specific care using the training cohort. Then, based on the results of LASSO regression analysis, multivariable logistic regression analysis was performed to establish the prediction nomogram. The calibration and discrimination of the nomogram were evaluated in the training cohort and validated in the validation cohort. Finally, the clinical usefulness was determined by decision curve analysis (DCA).

RESULTS

Age, the American Society of Anesthesiologists (ASA) score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were selected for the model. The concordance index (C-index) of the model was 0.843 in the training cohort and 0.831 in the validation cohort. The calibration curves of the ICU-specific care risk nomogram suggested great agreement in both training and validation cohorts. The DCA showed that the nomogram was clinically useful.

CONCLUSIONS

Age, ASA score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were identified as risk factors for ICU-specific care after gastric surgery. A clinically friendly model was generated to identify those most likely to require intensive care.

The Clinical Impact of Advanced Age on the Postoperative Outcomes of Patients Undergoing Gastrectomy for Gastric Cancer: Analysis Across US Hospitals Between 2011–2017

Purpose

This study systematically evaluated the implications of advanced age on post-surgical outcomes following gastrectomy for gastric cancer using a national database.

Materials and Methods

The 2011–2017 National Inpatient Sample was used to isolate patients who underwent gastrectomy for gastric cancer. From this, the population was stratified into those belonging to the younger age cohort (18–59 years), sexagenarians, septuagenarians, and octogenarians. The younger cohort and each advanced age category were compared in terms of the following endpoints: mortality following surgery, length of hospital stay, charges, and surgical complications.

Results

This study included a total of 5,213 patients: 1,366 sexagenarians, 1,490 septuagenarians, 743 octogenarians, and 1,614 under 60 years of age. Between the younger cohort and sexagenarians, there was no difference in mortality (2.27 vs. 1.67%; P=0.30; odds ratio [OR], 1.36; 95% confidence interval [CI], 0.81–2.30), length of stay (11.0 vs. 11.1 days; P=0.86), or charges ($123,557 vs. $124,425; P=0.79). Compared to the younger cohort, septuagenarians had higher rates of in-hospital mortality (4.30% vs. 1.67%; P<0.01; OR, 2.64; 95% CI, 1.67–4.16), length of stay (12.1 vs. 11.1 days; P<0.01), and charges ($139,200 vs. $124,425; P<0.01). In the multivariate analysis, septuagenarians had higher mortality (P=0.01; adjusted odds ratio [aOR], 2.01; 95% CI, 1.18–3.43). Similarly, compared to the younger cohort, octogenarians had a higher rate of mortality (7.67% vs. 1.67%; P<0.001; OR, 4.88; 95% CI, 3.06–7.79), length of stay (12.3 vs. 11.1 days; P<0.01), and charges ($131,330 vs. $124,425; P<0.01). In the multivariate analysis, octogenarians had higher mortality (P<0.001; aOR, 4.03; 95% CI, 2.28–7.11).

Conclusions

Advanced age (>70 years) is an independent risk factor for postoperative death in patients with gastric cancer undergoing gastrectomy.

A Practical Nomogram for Predicting the Prognosis of Elderly Patients with Gastric Adenocarcinoma After Gastrectomy

Purpose

To establish a pragmatic prognostic nomogram for predicting the survival of elderly patients undergoing gastrectomy for gastric adenocarcinoma.

Patients and Methods

Data of elderly patients undergoing gastrectomy for gastric adenocarcinoma between 2004 and 2015 were obtained from the Surveillance, Epidemiology, and End Results database. Prognostic factors were identified by the Kaplan–Meier method and the Cox proportional hazards model. Based on these factors, we developed a nomogram to predict the overall survival (OS) and gastric cancer-specific survival (GCSS). Concordance index (C-index) and calibration curve are employed to assess the predictive accuracy of the model. Decision curve analysis (DCA) and receiver operating characteristic curve (ROC) analysis are applied to further appraise the clinical utility of the model.

Results

A total of 8401 cases were incorporated into this research. After univariate and multivariate analyses, nine prognostic factors of OS were identified, including age (P < 0.001), race (P < 0.001), marital status (P < 0.001), tumor site (P < 0.001), tumor size (P = 0.024), differentiation (P < 0.001), T stage (P < 0.001), N stage (P < 0.001), and M stage (P < 0.001); ten prognostic factors of GCSS were identified, including age (P < 0.001), race (P < 0.001), tumor site (P < 0.001), tumor size (P = 0.002), differentiation (P < 0.001), T stage (P < 0.001), N stage (P < 0.001), M stage (P < 0.001), radiotherapy (P < 0.001) and chemotherapy (P < 0.001). The C-index of the constructed nomogram for OS was 0.708 (95% CI: 0.701–0.715) while for GCSS was 0.745 (95% CI: 0.737–0.753). The calibration curves of the nomogram predictions and actual observations displayed good agreement for the 3- and 5-year OS and GCSS probabilities. The results of DCA and the area under the curve calculated by ROC analysis showed that the developed model was superior than TNM stage.

Conclusion

The nomogram we established could accurately predict the prognosis of individual elderly patients who underwent gastrectomy for gastric adenocarcinoma.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Risk factors associated with postoperative morbidity and mortality in D2 radical gastrectomy for gastric cancer

INTRODUCTION AND AIMS

Surgery is the main treatment for gastric cancer. D2 radical gastrectomy is associated with a variable postoperative morbidity and mortality rate worldwide. The aim of the present study was to identify the risk factors associated with the postoperative morbidity and mortality of D2 radical gastrectomy, with curative intent, for gastric cancer.

MATERIALS AND METHODS

A retrospective case series was conducted, in which the medical records were reviewed of patients with gastric cancer that underwent D2 radical gastrectomy, within the time frame of January 2014 and December 2018. Univariate and multivariate analyses were carried out to identify the risk factors related to postoperative morbidity and mortality within 90 days.

RESULTS

The percentages of postoperative morbidity and mortality in 691 patients were 23.3% and 3.3%, respectively. In the multivariate analysis, age ≥70 years (OR = 1.85, 95% CI: 1.25-2.76), ASA III-IV (OR = 2.06, 95% CI: 1.28-3.34), total gastrectomy (OR = 1.96, 95% CI:1.19-3.23), and pancreatosplenectomy (OR = 5.41, 95% CI: 1.42-20.61) were associated with greater postoperative morbidity, and age ≥70 years (OR = 4.92, 95% CI:1.78-13.65), lower BMI (OR = 0.81, 95% CI: 0.71-0.92), and hypoalbuminemia (OR = 0.91, 95% CI: 0.85-0.98) were associated with greater mortality in distal and total D2 radical gastrectomy.

CONCLUSIONS

D2 radical gastrectomy for gastric cancer was shown to be a safe treatment, with low postoperative morbidity and mortality rates. Age ≥70 years, ASA III-IV, total gastrectomy, and pancreatosplenectomy were factors associated with a higher complication rate. Age ≥70 years, lower BMI, and hypoalbuminemia were mortality predictors in distal and total radical gastrectomy.

Risk factors associated with postoperative morbidity and mortality in D2 radical gastrectomy for gastric cancer

INTRODUCTION AND AIMS

Surgery is the main treatment for gastric cancer. D2 radical gastrectomy is associated with a variable postoperative morbidity and mortality rate worldwide. The aim of the present study was to identify the risk factors associated with the postoperative morbidity and mortality of D2 radical gastrectomy, with curative intent, for gastric cancer.

MATERIALS AND METHODS

A retrospective case series was conducted, in which the medical records were reviewed of patients with gastric cancer that underwent D2 radical gastrectomy, within the time frame of January 2014 and December 2018. Univariate and multivariate analyses were carried out to identify the risk factors related to postoperative morbidity and mortality within 90 days.

RESULTS

The percentages of postoperative morbidity and mortality in 691 patients were 23.3% and 3.3%, respectively. In the multivariate analysis, age ≥ 70 years (OR=1.85, 95% CI: 1.25-2.76), ASA III-IV (OR=2.06, 95% CI: 1.28-3.34), total gastrectomy (OR=1.96, 95% CI:1.19-3.23), and pancreatosplenectomy (OR=5.41, 95% CI: 1.42-20.61) were associated with greater postoperative morbidity, and age≥70 years (OR=4.92, 95% CI:1.78-13.65), lower BMI (OR=0.81, 95% CI: 0.71-0.92), and hypoalbuminemia (OR=0.91, 95% CI: 0.85-0.98) were associated with greater mortality in distal and total D2 radical gastrectomy.

CONCLUSIONS

D2 radical gastrectomy for gastric cancer was shown to be a safe treatment, with low postoperative morbidity and mortality rates. Age≥70 years, ASA III-IV, total gastrectomy, and pancreatosplenectomy were factors associated with a higher complication rate. Age≥70 years, lower BMI, and hypoalbuminemia were mortality predictors in distal and total radical gastrectomy.

Changing trends of clinicopathologic features and survival duration after surgery for gastric cancer in Northeast China

BACKGROUND

Through analyzing the data from a single institution in Northeast China, this study revealed the possible clinicopathologic characteristics that influence the prognosis of patients with gastric cancer (GC).

AIM

To evaluate the changing trends of clinicopathologic features and survival duration after surgery in patients with GC in Northeast China, which is a high-prevalence area of GC.

METHODS

The study analyzed the difference in clinicopathologic features and survival duration after surgery of 5887 patients who were histologically diagnosed with GC at the Harbin Medical University Cancer Hospital. The study mainly analyzed the data in three periods, 2000 to 2004 (Phase 1), 2005 to 2009 (Phase 2), and 2010 to 2014 (Phase 3).

RESULTS

Over time, the postoperative survival rate significantly increased from 2000 to 2014. In the past 15 years, compared with Phases 1 and 2, the tumor size was smaller in Phase 3 (P < 0.001), but the proportion of high-medium differentiated tumors increased (P < 0.001). The proportion of early GC gradually increased from 3.9% to 14.4% (P < 0.001). A surprising improvement was observed in the mean number of retrieved lymph nodes, ranging from 11.4 to 27.5 (P < 0.001). The overall 5-year survival rate increased from 24% in Phase 1 to 43.8% in Phase 3. Through multivariate analysis, it was found that age, tumor size, histologic type, tumor-node-metastasis stage, depth of invasion, lymph node metastasis, surgical approach, local infiltration, radical extent, number of retrieved lymph nodes, and age group were independent risk factors that influenced the prognosis of patients with GC.

CONCLUSION

The clinical features of GC in Northeast China changed during the observation period. The increasing detection of early GC and more standardized surgical treatment effectively prolonged lifetimes.

Gastric cancer in young patients: a separate entity with aggressive features and poor prognosis

PURPOSE

To investigate the clinicopathological features and survival outcomes between young and old patients with gastric cancer (GC), and further determine the role of young age in the prognosis of GC.

METHODS

Patients with stage I-III gastric adenocarcinomas undergoing curative surgery were enrolled, divided into young (aged 18-49 years, YG), middle-aged (50-59 years, MG), and old (≥ 60 years, OG) groups. Exclusion criteria were neoadjuvant therapy and history of malignant tumors. Clinicopathological features, overall survival (OS), disease-free survival (DFS), and recurrence patterns were compared among three groups.

RESULTS

1131 patients were finally included, with 270, 314, and 547 cases in the YG, MG, and OG, respectively. Compared to others, YG had higher proportion of female, middle-third gastric cancer, poor differentiation, N3b stage, and adjuvant chemotherapy. YG demonstrated poorer 5-year OS than MG (62.4% vs. 70.8%, P = 0.019), but better than OG (62.4% vs. 58.7%, P = 0.031). YG also suffered inferior 5-year DFS (75.2% vs. 82.8%, P = 0.040) compared with MG, and higher incidence of peritoneal recurrence than MG (15.1% vs. 5.2%, P < 0.001) and OG (15.1% vs. 4.1%, P < 0.001). Multivariate analysis identified young age as the independent prognostic factor for OS [hazard ratio (HR) = 1.347, 95% CI 1.018-1.781, P = 0.037], DFS (HR = 1.601, 95% CI 1.079-2.376, P = 0.019), and peritoneal recurrence (HR = 2.936, 95% CI 1.505-5.726, P = 0.002).

CONCLUSIONS

Young GC patients demonstrated aggressive features with poor prognosis and enhanced management may be warranted for this subgroup.

A New Nomogram Based on Early Postoperative NLR for Predicting Infectious Complications After Gastrectomy

Purpose

Our study aimed to construct a visible model to evaluate the risk of infectious complications after gastrectomy.

Methods

The clinical data of 856 patients who underwent gastrectomy were used to retrieve medical records. Univariate and multivariate analyses were performed to correlate early postoperative NLR and operative variables with postoperative complications, and the construction of the nomogram was based on logistic regression. The concordance index and receiver operating characteristic curves were used to evaluate the model performance.

Results

The postoperative infectious and noninfectious complication rates after gastrectomy were 18.5% (158/856 cases) and 12.3% (105/856 cases) respectively. Postoperative NLR (within 24 h) independently predicted the development of postoperative infectious complication. Multivariate analysis revealed that age, diabetes, body mass index (BMI), intraoperative blood transfusion and postoperative NLR were independent risk factors. The nomogram model showed a good performance in terms of predicting infectious complications after gastrectomy (concordance index=0.718).

Conclusion

Age, diabetes, BMI, intraoperative blood transfusion and postoperative NLR were independent risk factors of postoperative infectious complications after gastrectomy, and a novel nomogram based on these results can be used to predict postoperative infection and has the advantages of simple application and easy access.

Controlling Nutritional Status (CONUT) Score Is A Predictor Of Post-Operative Outcomes In Elderly Gastric Cancer Patients Undergoing Curative Gastrectomy: A Prospective Study

Purpose

The Controlling Nutritional Status (CONUT) score is a recently developed measure that is calculated using the serum albumin level, total cholesterol level, and lymphocyte counts. The aim of this study was to examine whether the CONUT score can predict post-operative outcomes in elderly patients undergoing curative gastrectomy.

Patients and methods

Pre-operative CONUT scores were evaluated from August 2014 to September 2016 in 357 gastric cancer patients who were scheduled to undergo curative gastrectomy. The patients were divided into three groups according to pre-operative CONUT scores: normal, light, moderate, and severe. We then calculated the association between the patient’s CONUT score and post-operative complications.

Results

CONUT scores were statistically associated with age (P = 0.015), body mass index (P < 0.001), pre-operative hemoglobin level (P < 0.001), tumor-node-metastasis stage (P < 0.001), surgical method (P = 0.036), and post-operative complications (P < 0.001). Multivariate analysis showed that age and the CONUT score were independent predictors of post-operative complications and 1-year survival.

Conclusion

CONUT scores can be used to predict post-operative complications and 1-year survival in elderly gastric cancer patients undergoing curative gastrectomy. They can also be used to classify the nutritional status of patients, which can be helpful for pre–and post-operative nutritional management.

Predicting overall and major postoperative morbidity in gastric cancer patients

BACKGROUND

Postoperative complications after gastric cancer resection vary in different series and they might have a significant impact in long-term outcomes. Our aim was to build a prediction rule on gastric cancer patients' overall and major morbidity risks.

METHODS

This retrospective study included 1223 patients from a single center who were resected between 1992 and 2016. Overall and major morbidity predictors were identified through multiple logistic regression. Models' performances were assessed through discrimination, calibration, and cross-validation, and nomograms were constructed.

RESULTS

The mean age was 61.3-year old and the male gender was more frequent (60%). The most common comorbidities were hypertension (HTN), diabetes, and chronic obstructive pulmonary disease (COPD). A D2-distal gastrectomy was the most frequent procedure and 87% of all lesions were located in the middle or distal third. Age, COPD, coronary heart disease, chronic liver disease, pancreatic resection, and operative time were independent predictors of overall and major morbidity. The extent of resection and splenectomy was associated with overall events and HTN with major ones. Both models were very effective in predicting events among patients at higher risk.

CONCLUSIONS

The overall and major morbidity models and nomograms included clinical- and surgical-related data that were very effective in predicting events, especially for high-risk patients.

Retrospective analysis of 1-year mortality after gastric cancer surgery: Total intravenous anesthesia versus volatile anesthesia

BACKGROUND

It remains controversial whether propofol-based total intravenous anesthesia (TIVA) or inhalation anesthesia is associated with better outcomes after cancer surgery. We investigated whether there is a difference in the 1-year overall or cancer-related mortality between propofol-based TIVA and inhalation anesthesia in patients who underwent gastric cancer surgery.

METHODS

This retrospective cohort study was based on medical records of ll patients aged ≥18 years who underwent elective gastric cancer surgery with curative intent between January 2005 and December 2015 at a single tertiary academic hospital. Propensity score (PS) matching and Cox proportional hazard models were used for analyses.

RESULTS

After PS matching, 1538 patients (769 patients in each group) were included in the final analysis. The 1-year overall mortality risk was not significantly different between the TIVA and inhalation groups in either the PS-matched analysis [hazard ratio (HR): 0.92, 95% confidence interval (CI): 0.52-1.64; P = 0.774] or entire cohorts (HR: 0.82 95% CI: 0.52-1.33; P = 0.417) after multivariable adjustment. The 1-year cancer-related mortality risk was similar between the groups in both the PS-matched cohort (HR: 0.91, 95% CI: 0.50-1.67; P = 0.764) and the entire cohort after multivariable adjustment (HR: 0.82, 95% CI: 0.50-1.33; P = 0.406).

CONCLUSIONS

We show that propofol-based TIVA was not significantly associated with a decrease in the 1-year overall or cancer-related mortality after gastric cancer surgery, as compared with inhalation anesthesia. Further studies are required to ascertain the optimal anesthetic choice for gastric cancer surgery.

Impact of age on stage-specific mortality in patients with gastric cancer: A long-term prospective cohort study

Controversies exist regarding the impact of age on gastric cancer-related mortality according to cancer stage. In our prospective cohort study, we evaluated the impact of age on stage-specific mortality in patients with gastric cancer. Between 2002 and 2006, patients with newly diagnosed gastric cancer were recruited from two university-affiliated hospitals in Korea. Follow-up data were updated regularly based on medical records and telephone surveys. Patients were classified into four subgroups according to age: <50, 50-59, 60-69, and 70-79 years. A total of 448 patients were followed up for 81.6 months (interquartile range, 25.0-139.3 months). The number of patients with stage I, II, III, and IV disease was 247, 74, 88, and 39, respectively. Overall, age was an independent risk factor for gastric cancer-specific mortality (hazard ratio [HR], [95% confidence interval (CI)]: 1.53 [0.91-2.57], 1.88 [1.21-2.91], and 2.64 [1.69-4.14] in the 50-59, 60-69, and 70-79 years groups, respectively, with the <50 years group as reference). In patients with stage I and II gastric cancer, the 70-79 years group was associated with a significantly higher rate of cancer-specific mortality than the <50 years group (stage I: HR [95% CI], 9.55 [2.11-43.12]; stage II: HR [95% CI], 7.17 [2.32-22.18]). However, age was not an independently associated factor for cancer-specific mortality in patients with stage III and IV gastric cancer. Although age was an independent risk factor for gastric cancer-related mortality in patients with gastric cancer, its impact may differ depending on the stage of cancer.

Recurrence after preoperative chemotherapy and surgery for gastric adenocarcinoma: a multicenter study

BACKGROUND

In most western European countries perioperative chemotherapy is a part of standard curative treatment for gastric cancer. Nevertheless, recurrence rates remain high after multimodality treatment. This study examines patterns of recurrence in patients receiving perioperative chemotherapy with surgery for gastric cancer in a real-world setting.

METHODS

All patients diagnosed with gastric adenocarcinoma between 2010 and 2015 who underwent at least preoperative chemotherapy and a gastrectomy with curative intent (cT1N+/cT2-4a,X; any cN; cM0) in 18 Dutch hospitals were selected from the Netherlands Cancer Registry. Additional data on chemotherapy and recurrence were collected from medical records. Rates, patterns, and timing of recurrence were examined. Multivariable Cox proportional hazard analyses were used to determine prognostic factors for recurrence.

RESULTS

408 patients were identified. After a median follow-up of 27.8 months, 36.8% of the gastric cancer patients had a recurrence of which the majority (88.8%) had distant metastasis. The 1-year recurrence-free survival was 71.8%. The risk of recurrence was higher in patients with an ypN+ stage (HR 4.92, 95% CI 3.35-7.24), partial or no tumor regression (HR 2.63, 95% CI 1.22-5.64), 3 instead of ≥ 6 chemotherapy cycles (HR 3.04, 95% CI 1.99-4.63), R1 resection (HR 1.52, 95% CI 1.02-2.26), and < 15 resected lymph nodes (HR 1.64, 95% CI 1.14-2.37).

CONCLUSION

A considerable amount of gastric cancer patients who were treated with curative intent developed a recurrence despite surgery and perioperative treatment. The majority developed distant metastases, therefore, multimodality treatment approaches should be focused on the prevention of distant rather than locoregional recurrences to improve survival.

Overall survival before and after centralization of gastric cancer surgery in the Netherlands

BACKGROUND

Centralization of surgery has been shown to improve outcomes for oesophageal and pancreatic cancer, and has been implemented for gastric cancer since 2012 in the Netherlands. This study evaluated the impact of centralizing gastric cancer surgery on outcomes for all patients with gastric cancer.

METHODS

Patients diagnosed with non-cardia gastric adenocarcinoma in the intervals 2009-2011 and 2013-2015 were selected from the Netherlands Cancer Registry. Clinicopathological data, treatment characteristics and mortality were assessed for the periods before (2009-2011) and after (2013-2015) centralization. Cox regression analyses were used to assess differences in overall survival between these intervals.

RESULTS

A total of 7204 patients were included. Resection rates increased slightly from 37·6 per cent before to 39·6 per cent after centralization (P = 0·023). Before centralization, 50·1 per cent of surgically treated patients underwent gastrectomy in hospitals that performed fewer than ten procedures annually, compared with 9·2 per cent after centralization. Patients who had gastrectomy in the second interval were younger and more often underwent total gastrectomy (29·3 per cent before versus 41·2 per cent after centralization). Thirty-day postoperative mortality rates dropped from 6·5 to 4·1 per cent (P = 0·004), and 90-day mortality rates decreased from 10·6 to 7·2 per cent (P = 0·002). Two-year overall survival rates increased from 55·4 to 58·5 per cent among patients who had gastrectomy (P = 0·031) and from 27·1 to 29·6 per cent for all patients (P = 0·003). Improvements remained after adjustment for case mix; however, adjustment for hospital volume attenuated this association for surgically treated patients.

CONCLUSION

Centralization of gastric cancer surgery was associated with reduced postoperative mortality and improved survival.