Helicobacter pylori infection and surgical disease--part II

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

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