Analysis of the impact of the body mass index in patients with gastric carcinoma

Association of preoperative body mass index with postoperative complications and survival for patients with gastric cancer: A systematic review and meta-analysis

OBJECTIVE

The relationship among body mass index (BMI), postoperative complications, and clinical outcomes in patients undergoing gastrectomy for gastric cancer remains unclear. This study aimed to evaluate this association using a meta-analysis.

METHOD

We conducted a systematic search of the PubMed, Embase, and Cochrane Library databases up to February 25, 2024. Patients were classified into underweight (<18.5 kg/m2), normal weight (18.5-25.0 kg/m2), and overweight (≥25.0 kg/m2) groups based on BMI categories. Meta-analysis was performed using a random-effects model. Additionally, exploratory sensitivity and subgroup analyses were performed.

RESULTS

Twenty-two studies involving 41,144 patients with gastric cancer were included for quantitative analysis. Preoperative underweight (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.03-1.55; P = 0.024) and overweight (OR: 1.19; 95%CI: 1.09-1.30; P <0.001) were associated with an increased risk of postoperative complications. Furthermore, preoperative underweight was associated with poorer overall survival (hazard ratio [HR]: 1.40; 95%CI: 1.28-1.53; P <0.001), whereas preoperative overweight was associated with better over-survival (HR: 0.82; 95%CI: 0.73-0.91; P <0.001). Furthermore, preoperative underweight was not associated with disease-free survival (HR: 1.48; 95%CI: 0.97-2.26; P = 0.069), whereas preoperative overweight was associated with longer disease-free survival (HR: 0.80; 95%CI: 0.70-0.91; P = 0.001). In terms of specific postoperative complications, preoperative underweight was associated with an increased risk of septic shock (OR: 3.40; 95%CI: 1.26-9.17; P = 0.015) and a reduced risk of fever (OR: 0.39; 95%CI: 0.18-0.83; P = 0.014). Preoperative overweight was associated with an increased risk of wound infections (OR: 1.78; 95%CI: 1.08-2.93; P = 0.023), intestinal fistula (OR: 5.23; 95%CI: 1.93-14.21; P = 0.001), arrhythmia (OR: 6.38; 95%CI: 1.70-24.01; P = 0.006), and pancreatic fistula (OR: 3.37; 95%CI: 1.14-9.96; P = 0.028).

CONCLUSION

This study revealed that both preoperative underweight and overweight status were associated with an increased risk of postoperative complications. Moreover, the postoperative survival outcomes were significantly better in overweight compared to that of underweight patients.

TRIAL REGISTRATION

Registration: INPLASY202480004.

Sex disparity, prediagnosis lifestyle factors, and long-term survival of gastric cancer: a multi-center cohort study from China

BACKGROUND

This multi-center cohort study aimed to investigate whether sex and prediagnosis lifestyle affect the prognosis of gastric cancer.

METHODS

Patients with gastric cancer were from four gastric cancer cohorts of the National Cancer Center of China, The First Hospital of Lanzhou University, Lanzhou University Second Hospital, and Gansu Provincial Cancer Hospital. Prediagnosis lifestyle factors in our study included body mass index (BMI) at diagnosis, usual BMI, weight loss, the history of Helicobacter pylori (Hp) infection, and the status of smoking and drinking.

RESULTS

Four gastric cancer cohorts with 29,779 gastric cancer patients were included. In total patients, female patients had a better prognosis than male patients (HR = 0.938, 95%CI: 0.881-0.999, P = 0.046). For prediagnosis lifestyle factors, BMI at diagnosis, usual BMI and the amount of smoking were statistically associated with the prognosis of gastric cancer patients. Female patients with smoking history had a poorer survival than non-smoking females (HR = 0.782, 95%CI: 0.616-0.993, P = 0.044). Tobacco consumption > 40 cigarettes per day (HR = 1.182, 95%CI: 1.035-1.350, P = 0.013) was independent adverse prognostic factors in male patients. Obesity paradox was observed only in male patients (BMI < 18.5, HR = 1.145, 95%CI: 1.019-1.286, P = 0.023; BMI: 23-27.4, HR = 0.875, 95%CI: 0.824-0.930, P < 0.001; BMI ≥ 27.5, HR = 0.807, 95%CI: 0.735-0.886, P < 0.001).

CONCLUSIONS

Sex and some prediagnosis lifestyle factors, including BMI at diagnosis, usual BMI and the amount of smoking, were associated with the prognosis of gastric cancer.

The impact of body mass index on short-term and long-term surgical outcomes of laparoscopic hepatectomy in liver carcinoma patients: a retrospective study

BACKGROUND

It was generally accepted that obesity could increase the morbidity and mortality of surgical patients. However, the influence of body mass index (BMI) on short-term and long-term surgical outcomes of laparoscopic hepatectomy (LH) for patients with liver carcinoma remains unclear. The aim of this study was to evaluate the influence of BMI on surgical outcomes.

METHODS

From August 2003 to April 2016, 201 patients with liver carcinoma who underwent LH were enrolled in our study. Based on their BMI in line with the WHO's definition of obesity for the Asia-Pacific region, patients were divided into three groups: underweight (BMI< 18.5 kg/m²), normal weight (18.5≤BMI< 23 kg/m²), and overweight (BMI≥ 23 kg/m²). Demographics and surgical outcomes of laparoscopic hepatectomy were compared in different BMI stratification. We investigated overall survival and relapse-free survival across the BMI categories.

RESULTS

Of the 201 patients, 23 (11.44%) were underweight, 96 (47.76%) were normal weight, and 82 (40.80%) were overweight. The overall complication rate in the underweight group was much higher than that in the normal weight and overweight groups (p=0.048). Postoperative complications, underweight patients developed grade III or higher Clavien-Dindo classifications (p=0.042). Among the three BMI groups, there were no significant differences in overall and relapse-free survival with Kaplan-Meier analysis (p=0.104 and p=0.190, respectively). On the other hand, gender, age, liver cirrhosis, bile leak, ascites, and Clavien classification (III-IV) were not independent risk factors for overall and relapse-free survival in multivariable Cox proportional hazards models.

CONCLUSIONS

BMI status does not affect patients with liver carcinoma long-term surgical outcomes concerned to overall survival and relapse-free survival after laparoscopic hepatectomy. However, being underweight was associated with an increased perioperative complication rate, and perioperative careful monitoring might be required after hepatectomy for underweight with liver carcinoma.

Impact of obesity on the outcomes after gastrectomy for gastric cancer: A meta-analysis

The impact of body mass index (BMI) on surgical outcomes has previously been studied in relation to several oncological procedures. Regarding gastric cancer surgery, published results have been contradicting in terms of degree of technical difficulty, risk of postoperative complications and survival. In an attempt to clarify these issues, we performed a meta-analysis to evaluate the impact of obesity (defined as BMI ≥ 30 kg/m²) on outcomes after gastrectomy for gastric cancer. The meta-analysis was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, EMBASE, Web of Science and Cochrane Library databases. Quality assessment was performed using the Newcastle-Ottawa scale. The meta-analysis was conducted using random-effects modeling. A total of 11 studies with 13 538 patients were eligible for analysis. Obesity was associated with a significantly longer operation time (WMD = 19.38 min, 95% CI 12.72-26.04; p < 0.001), increased risk of overall complications (RR = 1.23, 95% CI 1.06-1.42; p = 0.005) and pulmonary complications (RR = 3.81, 95% CI 2.24-6.46; p < 0.001). These findings remained irrespective type of surgery (laparoscopic vs. open) and type of gastrectomy. No differences were found regarding blood loss, number of resected lymph nodes, anastomotic leakage, hospital stay, 30-day mortality and 5-year overall survival. The conclusion of the current meta-analysis is that high BMI in gastric cancer patients is associated with longer operative time and more frequent overall postoperative complications. However, it has no negative impact on survival, indicating that gastrectomy is a safe procedure for this group of patients.

Relationship between the Body Mass Index and Tumor Site Postoperative Complications and Prognosis in Gastric Adenocarcinoma

The impact of BMI on survival in gastric cancer (GC) is not clear. We sought to explore the relationship between BMI and tumor site, clinicopathologic characteristics, postoperative complications, and prognosis in GC patients. Patients who underwent gastrectomy for GC between January 2011 and June 2016 formed the study cohort (n = 827). Patients were divided into three groups according to the BMI (in kg/m2): “low” (<18.5), “normal” (18.5–24.9), and “high” (≥25.0). The preoperative level of albumin and hemoglobin in the low BMI group was lower than that in the high BMI or normal BMI group ( P < 0.05). The prevalence of gastric-cardia cancer in the high BMI group was significantly higher than that in the low BMI group ( P = 0.001). The prevalence of gastric-antrum cancer in the high BMI group was significantly lower than that in the low BMI group ( P = 0.001) and the normal BMI group ( P = 0.004). The BMI of patients with gastric-cardia cancer was significantly higher than that of patients with gastric-body cancer ( P = 0.018) and gastric-antrum cancer ( P < 0.001). There were no significant differences among the three groups in terms of tumor size, TNM stage, depth of tumor invasion, degree of tumor differentiation, resection margin, lymph node metastasis, or postoperative complications. BMI was not an independent factor that influenced the prognosis. We found a relationship between BMI and GC site. A low BMI may be associated with a poor prognosis and a high BMI may be related to a favorable prognosis. BMI was not an independent factor that influenced GC prognosis.

Does high body mass index negatively affect the surgical outcome and long-term survival of gastric cancer patients who underwent gastrectomy: A systematic review and meta-analysis

BACKGROUND

Whether high body mass index (BMI) was associated with increased postoperative complications and unfavorable prognosis of gastric cancer (GC) patients remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the impact of high BMI on surgical outcome, postoperative complications and long-term survival of GC patients.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the BMI, all GC patients were classified into BMI ≥25 kg/m² group and BMI <25 kg/m² group. The relevant data was extracted and pooled effect size was assessed using a fixed effect model or random effect model.

RESULTS

A total of 36 relevant studies involving 30,642 GC patients were included in this meta-analysis. The results indicated that high BMI patients had longer operation time, fewer number of retrieved lymph nodes and larger amount of intraoperative blood loss than other patients, regardless of open gastrectomy or laparoscopic gastrectomy. In addition, the risk of postoperative complications was significantly higher in the patients with BMI ≥25 kg/m² than in those with BMI <25 kg/m², especially for infectious complications. However, high BMI had no negative impact on postoperative mortality and long-term survival of GC patients.

CONCLUSION

Despite the increased surgical difficulty and postoperative complications, high BMI was not associated with the prognosis of GC patients. To reduce the risk of postoperative complications, more meticulous operation technique and improved perioperative management should be necessary for high BMI patients.

Outcome predictors for patients with stage II/III gastric cancer who undergo gastrectomy and S-1 adjuvant chemotherapy

Predictors of survival in patients with stage II/III gastric cancer (GC) who received tegafur/gimeracil/oteracil (S-1) adjuvant chemotherapy (ACT) subsequent to gastrectomy were examined. Additionally, the association between dose intensity of S-1 and survival rate was investigated. A total of 62 patients with stage II/III gastric cancer were retrospectively evaluated, each of whom had received a curative D2 gastrectomy and S-1 ACT. The relative performance (RP; administered/planned S-1 doses ×100%), body mass index (BMI), prognostic nutritional index (PNI) and body weight (BW) were calculated, and the association of survival with these factors and other clinicopathological parameters was examined. The 1-year treatment continuation rate for S-1 was 94.2%, excluding patients who experienced cancer recurrences during their ACT year. The initial S-1 reduction rate was 38.7%. Patients with stage II/IIIA disease exhibited significantly improved 5-year overall survival rates compared with patients with stage IIIB GC, 81.6/73.7 vs. 33.8% (P<0.01). No association between RP and survival was observed. BMI, BW and PNI were significantly decreased following surgery compared with preoperative states. In the univariate analysis, postoperative BW loss (BMI loss), pathological stage and >7 lymph node metastases were significantly associated with outcome (P<0.05); in the multivariate analysis, postoperative BW loss >10.6% and pathological stages were independent prognostic factors for survival. Continuing S-1 ACT for the full year exhibited a greater effect on survival compared with dosage. Early postoperative nutritional deterioration may decrease the survival rates in these patients.

Demographic and lifestyle factors and survival among patients with esophageal and gastric cancer: The Biobank Japan Project

Background

Several studies have evaluated associations between the characteristics of patients with esophageal and gastric cancer and survival, but these associations remain unclear. We described the distribution of demographic and lifestyle factors among patients with esophageal and gastric cancer in Japan, and investigated their potential effects on survival.

Methods

Between 2003 and 2007, 24- to 95-year-old Japanese patients with esophageal and gastric cancer were enrolled in the BioBank Japan Project. The analysis included 365 patients with esophageal squamous cell carcinoma (ESCC) and 1574 patients with gastric cancer. Hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality were estimated using medical institution-stratified Cox proportional hazards models.

Results

During follow-up, 213 patients with ESCC (median follow-up, 4.4 years) and 603 patients with gastric cancer (median follow-up, 6.1 years) died. Among patients with ESCC, the mortality risk was higher in ever drinkers versus never drinkers (multivariable HR = 2.37, 95% CI: 1.24, 4.53). Among patients with gastric cancer, the mortality risk was higher in underweight patients versus patients of normal weight (multivariable HR = 1.66, 95% CI: 1.34, 2.05). Compared to patients with gastric cancer with no physical exercise habit, those who exercised ≥3 times/week had a lower mortality risk (multivariate HR = 0.75, 95% CI = 0.61, 0.93). However, lack of stage in many cases was a limitation.

Conclusions

Among patients with ESCC, alcohol drinkers have a poor prognosis. Patients with gastric cancer who are underweight also have a poor prognosis, whereas patients with physical exercise habits have a good prognosis.

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Among ESCC patients, alcohol drinkers had a poor prognosis.

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Underweight gastric cancer patients had a poor prognosis.

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Gastric cancer patients who exercised had a good prognosis.

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No association between esophageal or gastric cancer and smoking was observed.

Influence of Visceral Fat on Early Postoperative Outcomes After Distal and Total Gastrectomy for Gastric Cancer

We studied the influence of visceral fat area (VFA) on early postoperative outcomes separately after distal and total gastrectomy. The influence of obesity on outcomes might differ between distal and total gastrectomy, but few studies have directly compared the effects of VFA on early postoperative results between these 2 procedures. We reviewed clinical records of 124 patients with gastric cancer undergoing curative distal or total gastrectomy. Patients were classified into 2 groups: low (&lt;100 cm2) or high (≥100 cm2) VFA. Patient characteristics and early postoperative outcomes were compared between 2 groups separately in distal or total gastrectomy. There were 77 and 47 patients who underwent distal and total gastrectomy, respectively. After distal gastrectomy, operation time (268 ± 44 versus 239 ± 39 minutes, P &lt; 0.05) as well as blood loss (351 ± 231 versus 239 ± 147 mL, P &lt; 0.05) was increased in the high VFA group (N = 32) compared to the low VFA group (N = 45), but morbidity rates did not differ between the 2 groups (50% versus 36%). After total gastrectomy; operation time (285 ± 42 versus 260 ± 53 minutes, P &lt; 0.05); blood loss (427 ± 326 versus 280 ± 179 mL, P &lt; 0.05); rate of morbidity (56% versus 24%, P &lt; 0.05); and intra-abdominal infection (17% versus 0%, P &lt; 0.05) were increased in the high VFA group (N = 18) compared to the low VFA group (N = 29). These results suggest that postoperative morbidity increases after total gastrectomy but not after distal gastrectomy in patients with excessive visceral fat.

A Prognostic Model Using Inflammation- and Nutrition-Based Scores in Patients With Metastatic Gastric Adenocarcinoma Treated With Chemotherapy

The outcomes of patients with metastatic gastric cancer (mGC) are poor. Recent studies have identified the prognostic impact of inflammatory response and nutritional status on survival for patients with gastric cancer. This study aims to create a prognostic model using inflammatory- and nutrition-based scores to predict survival in patients with mGC treated with chemotherapy.After institutional review board approval, patients who had mGC and were treated with chemotherapy from 2007 to 2012 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Significantly predictive factors were identified by multivariate Cox regression analyses. Based on these variables, a prognostic model using inflammatory- and nutrition-based scores was constructed to predict survival. Kaplan-Meier curves were plotted to estimate overall survival. The c-statistic values with 95% confidence interval (CI) were also calculated to access their predicting performances.Our study consisted of 256 patients with a median age of 60 years and a median follow-up visit of 18.5 months. Multivariate analyses showed that neutrophil to lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), and Patient-Generated Subjective Global Assessment (PG-SGA) were independently related to survival. After computing these scores, patients were classified into favorable-, intermediate-, and poor-risk groups. The median overall survival were 27.6 versus 13.2 versus 8.2 months in favorable, intermediate, and poor-risk groups, respectively. The 2-year survival rate was 52% versus 16% versus 3% in favorable-, intermediate-, and poor-risk groups, respectively. (P < 0.001). The c-statistic value of our model at 2 years is 0.8 (95% CI, 0.75-0.86).NLR, mGPS, and PG-SGA were independently related to survival. Our prognostic model using inflammatory- and nutrition-based scores could provide prognostic information to patients and physicians.

Clinical application of ghrelin in the field of surgery

Ghrelin was discovered as an intrinsic ligand for the growth hormone (GH)-secretagogue receptor (GHS-R) in 1999. The endogenous production of ghrelin occurs mainly in the stomach. Ghrelin has multiple functions; it has orexigenic action, stimulates GH secretion, has anti-inflammatory activities, stimulates gastrointestinal activity, stabilizes heart function and has other metabolic roles. Moreover, ghrelin is the only gastrointestinal hormone known to stimulate appetite. In the past decade, clinical applications of ghrelin have been attempted for various pathologies, based on its anabolic function, including applications for patients with anorexia nervosa and cachexia due to chronic heart, renal or pulmonary diseases. In the field of surgery, we have conducted several clinical trials using exogenous ghrelin in patients undergoing total gastrectomy, esophagectomy and neoadjuvant chemotherapy, including cisplatin treatment, and consistently obtained unique and striking benefits in these patients. Ghrelin comprehensively improves the patients' general conditions and quality of life via its pleiotropic physiological functions. This characteristic is unique and different from the existing drugs; therefore, ghrelin may be an indispensable supplement to prevent surgical stress and postoperative sequelae. This review summarizes the recent advances toward the clinical application of ghrelin.

Family history, body mass index and survival in Japanese patients with stomach cancer: a prospective study

Family history and nutritional status may affect the long-term prognosis of stomach cancer, but evidence is insufficient and inconsistent. To clarify the prognostic factors of stomach cancer, we conducted a prospective study of 1,033 Japanese patients with histologically confirmed stomach cancer who were admitted to a single hospital between 1997 and 2005. Family history of stomach cancer and pretreatment body mass index (BMI) were assessed using a self-administered questionnaire. Clinical data were retrieved from a hospital-based cancer registry. All patients were completely followed up until December, 2008. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated according to family history in parents and siblings and BMI category. During a median follow-up of 5.3 years, 403 all-cause and 279 stomach cancer deaths were documented. Although no association with family history was observed in the patients overall, analysis according to age group found an increased risk of all-cause death associated with a history in first degree relatives (HR = 1.61, 95% CI: 0.93-2.78, p = 0.09) and with a parental history (HR = 1.86, 95% CI: 1.06-3.26) among patients aged under 60 years at diagnosis. BMI was related to all-cause and stomach cancer death among patients aged 60 and over, showing a J-shaped pattern (HR of all-cause death = 2.28 for BMI < 18.5; HR = 1.61 for 25 ≤ vs. ≥ 23.0 to < 25.0 kg/m(2)). A family history of stomach cancer, especially parental history, may affect mortality among younger stomach cancer patients, whereas nutritional status may be a prognostic factor in older patients.

Does overweight affect outcomes in patients undergoing gastrectomy for cancer? A meta-analysis of 25 cohort studies

OBJECTIVE

Overweight was regarded as one of the risk factors for poor outcome after gastrectomy, but its influence on the surgical and postoperative outcomes of gastrectomy was unclear.

METHODS

Comprehensive searches were conducted to include cohort studies which evaluated the influence of overweight on the surgical and postoperative outcomes of gastrectomy. Data was analyzed by RevMan 5.0.

RESULTS

Twenty-five cohort studies (18 518 patients) were included. Overweight patients were associated with longer operation time (mean difference 20.88, 95% confidence interval 14.07, 27.69), more intraoperative blood loss (mean difference 35.45, 95% confidence interval 9.24, 61.67), and less retrieved lymph nodes (mean difference -2.17, 95% confidence interval -3.51, -0.83) than normal patients undergoing laparoscopy-assisted gastrectomy. And overweight patients were associated with longer operation time (mean difference 26.31, 95% confidence interval 21.92, 30.70), more intraoperative blood loss (mean difference 130.02, 95% confidence interval 75.49, 184.55), less retrieved lymph nodes (mean difference -3.18, 95% confidence interval -4.74, -1.61), longer postoperative hospital stay (mean difference 2.37, 95% confidence interval 0.03, 4.70) and more postoperative complications (risk ratio 1.53, 95% confidence interval 1.29, 1.80) than normal patients in open gastrectomy.

CONCLUSIONS

Overweight might affect the clinical results of both laparoscopy-assisted and open gastrectomy, especially for open gastrectomy.

Patients with old age or proximal tumors benefit from metabolic syndrome in early stage gastric cancer

Background

Metabolic syndrome and/or its components have been demonstrated to be risk factors for several cancers. They are also found to influence survival in breast, colon and prostate cancer, but the prognostic value of metabolic syndrome in gastric cancer has not been investigated.

Methods

Clinical data and pre-treatment information of metabolic syndrome of 587 patients diagnosed with early stage gastric cancer were retrospectively collected. The associations of metabolic syndrome and/or its components with clinical characteristics and overall survival in early stage gastric cancer were analyzed.

Results

Metabolic syndrome was identified to be associated with a higher tumor cell differentiation (P = 0.036). Metabolic syndrome was also demonstrated to be a significant and independent predictor for better survival in patients aged >50 years old (P = 0.009 in multivariate analysis) or patients with proximal gastric cancer (P = 0.047 in multivariate analysis). No association was found between single metabolic syndrome component and overall survival in early stage gastric cancer. In addition, patients with hypertension might have a trend of better survival through a good control of blood pressure (P = 0.052 in univariate analysis).

Conclusions

Metabolic syndrome was associated with a better tumor cell differentiation in patients with early stage gastric cancer. Moreover, metabolic syndrome was a significant and independent predictor for better survival in patients with old age or proximal tumors.