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Merga ZC, Lee JS, Gong CS. Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis. J Gastric Cancer 2023; 23:428-450. [PMID: 37553130 PMCID: PMC10412976 DOI: 10.5230/jgc.2023.23.e23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 08/10/2023] Open
Abstract
This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.
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Affiliation(s)
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chung-Sik Gong
- Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Shannon AB, Song Y, Fraker DL, Roses RE, DeMatteo RP, Miura JT, Karakousis GC. Surgical resection of gastric gastrointestinal stromal tumors (GIST) in octogenarians. Am J Surg 2021; 223:325-330. [PMID: 33867048 DOI: 10.1016/j.amjsurg.2021.03.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/25/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Localized gastrointestinal stromal tumors (GISTs) are rare tumors typically managed with surgery, but outcomes among octogenarians remain less studied. METHODS Octogenarian patients with stage I-III gastric GISTs were identified from the National Cancer Database and classified by resection status. Cox regression and Kaplan-Meier survival analyses analyzed 5-year overall survival (OS). Ninety-day mortality was analyzed following 1:1 propensity score matching. RESULTS Identified octogenarians (N = 949) who underwent resection (N = 632) had improved adjusted OS (71% vs 59.6%, HR 0.75, p 0.049) as compared to non-resected patients. Following matching, 90-day mortality was 5.7% and 11% in resected and non-resected patients (p 0.052), respectively. After exclusion of patients with 90-day mortality, resected patients maintained an OS advantage (77.3% vs 71.1%, HR 0.64, p 0.028). CONCLUSIONS The majority of octogenarians with localized gastric GIST are treated with surgery portending improved survival but an appreciable mortality, suggesting a necessity for careful selection of older patients for surgery.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
| | - Robert E Roses
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
| | - Ronald P DeMatteo
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA, 19146, USA
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Shannon AB, Straker RJ, Fraker DL, Roses RE, Miura JT, Karakousis GC. Ninety-day mortality after total gastrectomy for gastric cancer. Surgery 2021; 170:603-609. [PMID: 33789812 DOI: 10.1016/j.surg.2021.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/15/2021] [Accepted: 02/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Total gastrectomy for gastric cancer is associated with significant 30-day mortality, but this endpoint may underestimate the short-term mortality of the procedure. METHODS Retrospective analysis was performed using the National Cancer Database (2004-2015). Patients who underwent total gastrectomy for stage I to III gastric adenocarcinoma were identified and divided into cohorts based on 90-day mortality. Predictors of mortality were analyzed using multivariable logistic regression, and annual trends in mortality rates were calculated by Joinpoint Regression. RESULTS Of the 5,484 patients who underwent total gastrectomy, 90-day and 30-day mortality rates were 9.1% and 4.7%, respectively. Factors associated with 90-day mortality included increasing age (odds ratio 1.0, P < .001), income below the median (odds ratio 1.2, P = .039), Charlson-Deyo score ≥2 (odds ratio 1.4, P = .039), treatment at low-volume facilities (odds ratio 1.5, P < .001), N1 (odds ratio 2.0, P < .001), N2 (odds ratio 2.0, P < .001), or N3 (odds ratio 2.7, P < .001) stage disease, having <16 lymph nodes harvested (odds ratio 1.5, P < .001), and lack of treatment with chemotherapy (3.7, P < .001). Lack of health insurance (odds ratio 4.1, P = .080), and positive microscopic margins (odds ratio 1.3, P = .080) were correlated, but not significantly associated, with 90-day mortality. The 90-day mortality rate significantly declined from 14.3% in 2004 to 7.9% in 2015 (P = .006), and the 30-day mortality rate significantly declined from 7.7% in 2004 to 4.8% in 2015 (P = .009). CONCLUSION Nearly half of the deaths within 90 days after total gastrectomy for cancer occur beyond 30 days postoperative. Ninety-day mortality has improved over time, but rates remain high, suggesting the need for improved out-of-hospital postoperative care beyond 30 days.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA
| | - Richard J Straker
- Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA
| | - Robert E Roses
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Pennsylvania, PA.
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Chen E, Senders ZJ, Hardacre J, Kim J, Ammori J. Perioperative outcomes and survival of octogenarians undergoing curative resection for esophagogastric adenocarcinoma. J Surg Oncol 2020; 121:1015-1021. [PMID: 32090338 DOI: 10.1002/jso.25866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 02/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Current data are conflicting as to whether the outcomes of octogenarians undergoing resection for esophagogastric adenocarcinoma are comparable to younger patients. This study aims to compare perioperative outcomes and survival of patients ≥80 years old with younger patients undergoing curative resection for esophagogastric adenocarcinoma. METHODS Retrospective data were collected on 190 patients who underwent resection with curative intent for adenocarcinomas found in the stomach and esophagogastric junction from 2004 to 2015 at a single institution. RESULTS Of the 190 patients, 34 (18%) were ≥80 years old. Octogenarians were more likely to have chronic kidney disease (CKD) and were less likely to have received neoadjuvant chemotherapy. Pathologic features were similar between groups. Octogenarians' tumors were more likely to be located in the gastric body as compared to the esophagogastric junction in younger patients. Although the length of stay was comparable, octogenarians were significantly less likely to be discharged home (P < .01). Both groups had a single death during the index admission. Incidence and severity of 90 days postoperative complications were not significantly different between groups. There was no difference in 30-day, 90-day, 1-year, or median survival. CONCLUSIONS Perioperative outcomes and survival of octogenarians undergoing curative resection for esophagogastric cancer are comparable to younger patients at our institution.
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Affiliation(s)
- Eric Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Zachary J Senders
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey Hardacre
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Julian Kim
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - John Ammori
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Wang X, Zhao J, Fairweather M, Yang T, Sun Y, Wang J. Optimal treatment for elderly patients with resectable proximal gastric carcinoma: a real world study based on National Cancer Database. BMC Cancer 2019; 19:1079. [PMID: 31706283 PMCID: PMC6842542 DOI: 10.1186/s12885-019-6166-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 09/16/2019] [Indexed: 12/27/2022] Open
Abstract
Background High perioperative morbidity, mortality, and uncertain outcome of surgery in octogenarians with proximal gastric carcinoma (PGC) pose a dilemma for both patients and physicians. We aim to evaluate the risks and survival benefits of different strategies treated in this group. Methods Octogenarians (≥80 years) with resectable proximal gastric carcinoma who were recommended for surgery were identified from National Cancer Database during 2004–2013. Results Patients age ≥ 80 years with PGC were less likely to be recommended or eventually undergo surgery compared to younger patients. Patients with surgery had a significantly better survival than those without surgery (5-year OS: 26% vs. 7%, p < 0.001), especially in early stage patients. However, additional chemotherapy (HR: 0.94, 95% CI: 0.82–1.08, P = 0.36) or radiotherapy (HR: 0.97, 95% CI: 0.84–1.13, P = 0.72) had limited benefits. On multivariate analysis, surgery (HR: 0.66, 95% CI: 0.51–0.86, P = 0.002) was a significant independent prognostic factor, while extensive surgery had no survival benefit (Combined organ resection: HR: 1.88, 95% CI: 1.22–2.91, P = 0.004; number of lymph nodes examined: HR: 0.99, 95% CI: 0.97–1.00, P = 0.10). Surgery performed at academic and research (AR) medical center had the best survival outcome (5-year OS: 30% in AR vs. 18–27% in other programs, P < 0.001) and lowest risk (30-day mortality: 1.5% in AR vs. 3.6–6.6% in other programs, P < 0.001; 90-day mortality: 6.2% in AR vs. 13.6–16.4% in other programs, P < 0.001) compared to other facilities. Conclusions Less-invasive approach performed at academic and research medical center might be the optimal treatment for elderly patients aged ≥80 yrs. with early stage resectable PGC.
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Affiliation(s)
- Xuefei Wang
- Gastric Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Junjie Zhao
- Gastric Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Mark Fairweather
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Tingsong Yang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, 20072, China
| | - Yihong Sun
- Gastric Cancer Center, Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Xu Y, Wang Y, Xi C, Ye N, Xu X. Is it safe to perform gastrectomy in gastric cancer patients aged 80 or older?: A meta-analysis and systematic review. Medicine (Baltimore) 2019; 98:e16092. [PMID: 31192972 PMCID: PMC6587649 DOI: 10.1097/md.0000000000016092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Few studies have focused on octogenarian patients with gastric cancer (GC) who have undergone gastrectomy. This meta-analysis of published studies was performed to assess the safety of treating octogenarian GC patients with surgery. METHODS Databases, including PubMed, Embase, Web of Science, and Cochrane Library were searched until January 2019. The incidence of preoperative comorbidities, postoperative complications, and mortality was assessed using odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Further, the hazard ratios (HRs) with 95% CIs were applied for survival outcomes. RESULTS A total of 18,179 patients with GC in 21 studies were included. Our results demonstrated that octogenarian patients were associated with a higher burden of comorbidities (OR = 2.79; 95% CI: 2.37, 3.28; P = .00), high incidences of overall postoperative complications (OR = 1.48; 95% CI: 1.22, 1.81; P = .00), medical postoperative complications (OR = 2.58; 95% CI: 1.91, 3.49; P = .00), in-hospital mortality (OR = 3.24; 95% CI: 2.43, 4.31; P = .00) and poor overall survival (HR = 1.96; 95% CI: 1.65, 2.27; P = .00). CONCLUSIONS Considering the high burden of comorbidities, high incidences of postoperative complications and mortality, surgery for extremely elderly patients with GC requires deliberation. Individualized treatment is recommended for such patients.
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Batista Rodríguez G, Balla A, Fernández-Ananín S, Balagué C, Targarona EM. The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review. Surg Innov 2018; 25:400-412. [PMID: 29781362 DOI: 10.1177/1553350618775539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery. METHODS A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed. RESULTS A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery. CONCLUSIONS The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.
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Affiliation(s)
- Gabriela Batista Rodríguez
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,2 Unidad de Cirugía Oncológica, Departamento de Hemato-Oncologia, Hospital Dr. Rafael A. Calderón Guardia, Caja Costarricense del Seguro Social, San José, Costa Rica
| | - Andrea Balla
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,3 Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Sonia Fernández-Ananín
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Carmen Balagué
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Eduard M Targarona
- 1 General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
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