Total gastrectomy with "over-D1" lymph node dissection: what is the actual impact of age?

How could we identify the 'old' patient in gastric cancer surgery? A single centre cohort study

PURPOSE

To analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient.

METHODS

In a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable "age". All the significant variables were used to find predictors of complications with Clavien-Dindo>2.

RESULTS

Age>75 (AUC 0.61; 95% 0.55-0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54-0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00-1.01; p = 0.0001- AUC 0.62, 95% CI 0.56-0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04-0.93, p = 0.041 - AUC 0.74 95% CI 0.68-0.80; p = 0.003) and additional procedures (OR 7.05; 1.23-40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06-11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23-72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36-8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2.

CONCLUSIONS

Our work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events.

Prognostic risk factors of early gastric cancer-a western experience

PURPOSE

Lymph node metastasis (LNM) is the leading cause of tumor recurrence in early gastric cancer (EGC). Since endoscopic resection (ER) can be performed in EGC with curative intention when no LNM are present, this study wants to determine the risk factors for LNM in EGC.

METHODS

One hundred twenty-four patients who have had an operative resection because of EGC were analyzed. Histopathological workup included tumor infiltration depth, lymphatic and vascular infiltration, lymph node infiltration, tumor differentiation, and the classification of Ming. A complete follow-up was achieved.

RESULTS

There was no LNM among tumors meeting the standard or extended criteria for an ER. Lymphatic infiltration (p < 0.001) and infiltration of the submucosal layers (p = 0.018) proved to be the strongest risk factors for LNM. Tumors with a deeper infiltration depth (p = 0.015) and a lower grade of differentiation (p = 0.029) presented with a higher grade of lymphatic infiltration. Tumors located in the body of the stomach (p = 0.003) and tumors with infiltrative growth according to Ming (p = 0.021) had a significantly higher risk for lymphatic infiltration. The 5-year overall survival was 84 % in nodal negative patients and 42 % in patients with LNM (p = 0.002).

CONCLUSIONS

ER within the extended criteria with a meticulous histological workup should be performed in EGC to determine whether risk factors for LNM are present. If lymphatic infiltration is observed, surgery with lymphadenectomy is recommended. Tumors exceeding the extended criteria should undergo primary surgery with adequate lymphadenectomy.

Risk factors associated with complication following gastrectomy for gastric cancer: retrospective analysis of prospectively collected data based on the Clavien-Dindo system

BACKGROUND

Most studies about complication after gastric cancer surgery have been performed without consideration of the severity of each complication. The purposes of this study were to prospectively analyze all postgastrectomy complications according to severity using Clavien-Dindo classification and to identify risk factors related to postoperative complications.

METHODS

Complication data were collected prospectively through weekly conferences with all gastric adenocarcinoma patients who underwent gastrectomy between March 2011 and February 2012 at Seoul National University Hospital. Complications were categorized according to the Clavien-Dindo classification.

RESULTS

Out of the 881 patients who underwent gastrectomy, there were 254 events in 197 patients (22.4%). The numbers of grade I, II, IIIa, IIIb, IVa, and V complications according to the Clavien-Dindo classification were 71 (8.1%), 58 (6.6%), 108 (12.3%), 8 (0.9%), 5 (0.6%), and 4 (0.5%), respectively. Extended gastrectomy (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.96-7.82, p < 0.001), total gastrectomy (OR, 1.97; 95% CI, 1.24-3.14, p = 0.004), and age of 60 years or more (OR, 1.66; 95% CI, 1.15-2.38, p = 0.007) were found to be significant independent risk factors for overall complications of gastrectomy. These three factors were also risk factors for the complications of grade IIIa or over and local and systemic complications. In addition, ASA 3 or 4 and moderate or severe malnutrition as well as those three factors were risk factors for systemic complications.

CONCLUSION

Age and the extent of gastrectomy were revealed as the prognostic factors for overall complications and the complications of grade IIIa or over according to the Clavien-Dindo classification following gastrectomy for gastric cancer.

The impact of age and comorbidity on postoperative complications in patients with advanced gastric cancer after laparoscopic D2 gastrectomy: results from the Chinese laparoscropic gastrointestinal surgery study (CLASS) group

BACKGROUND

This study aims to evaluate the role of age and comorbidities on postoperative complications in the patients with advanced gastric cancer (AGC) following laparoscopy-assisted gastrectomy (LAG) and D2 lymphadenectomy based on the results from the Chinese Laparoscropic Gastrointestinal Surgery Study (CLASS) Group.

METHODOLOGY

From February 2003 and December 2009 at twenty-seven medical centers, 1184 AGC patients after LAG with D2 lymphadenectomy were entered and followed in a retrospective recorded database. The postoperative complications were recorded by using the Accordion Severity Grading System.

RESULTS

Postoperative morbidity and mortality after LAG and D2 dissection in the AGC patients was 10.1% and 0.1%, respectively. Multivariable analysis identified age ≥ 65 years (OR = 1.72, P = 0.024) and having two or more comorbidities (OR = 2.76, P = 0.009) as the significant predictors of the development of postoperative complications. Meanwhile, age ≥ 65 years (OR = 1.95, P = 0.016) and having two or more comorbidities (OR = 3.62, P = 0.001) were also the significant predictors of moderate or severe complications. In stratified analysis by the number of comorbidities, age ≥ 65 years was significantly associated with an excess risk of postoperative complications (OR = 2.35, P = 0.033), and the moderate or severe complications (OR = 4.36, P = 0.003) when the patients had at least one comorbidity.

CONCLUSIONS

LAG would be a safe and technically feasible approach for the AGC patients, despite age ≥65 years and having multiple comorbidities were the potential risk factors for postoperative complications. Importantly, elderly patients with resectable gastric cancer should not be excluded from the potential benefits of LAG provided that comorbidities are fully considered.