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Beyer K. Surgery Matters: Progress in Surgical Management of Gastric Cancer. Curr Treat Options Oncol 2023; 24:108-129. [PMID: 36656504 PMCID: PMC9883345 DOI: 10.1007/s11864-022-01042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 01/20/2023]
Abstract
OPINION STATEMENT The surgical treatment of gastric carcinoma has progressed significantly in the past few decades. A major milestone was the establishment of multimodal therapies for locally advanced tumours. Improvements in the technique of endoscopic resection have supplanted surgery in the early stages of many cases of gastric cancer. In cases in which an endoscopic resection is not possible, surgical limited resection procedures for the early stages of carcinoma are an equal alternative to gastrectomy in the field of oncology. Proximal gastrectomy is extensively discussed in this context. Whether proximal gastrectomy leads to a better quality of life and better nutritional well-being than total gastrectomy depends on the reconstruction chosen. The outcome cannot be conclusively assessed at present. For locally advanced stages, total or subtotal gastrectomy with D2 lymphadenectomy is now the global standard. A subtotal gastrectomy requires sufficiently long tumour-free proximal resection margins. Recent data indicate that proximal margins of at least 3 cm for tumours with an expansive growth pattern and at least 5 cm for those with an infiltrative growth pattern are sufficient. The most frequently performed reconstruction worldwide following gastrectomy is the Roux-en-Y reconstruction. However, there is evidence that pouch reconstruction is superior in terms of quality of life and nutritional well-being. Oncological gastric surgery is increasingly being performed laparoscopically. The safety and oncological equivalency were first demonstrated for early carcinomas and then for locally advanced tumours, by cohort studies and RCTs. Some studies suggest that laparoscopic procedures may be advantageous in early postoperative recovery. Robotic gastrectomy is also increasing in use. Preliminary results suggest that robotic gastrectomy may have added value in lymphadenectomy and in the early postoperative course. However, further studies are needed to substantiate these results. There is an ongoing debate about the best treatment option for gastric cancer with oligometastatic disease. Preliminary results indicate that certain patient groups could benefit from resection of the primary tumour and metastases following chemotherapy. However, the exact conditions in which patients may benefit have yet to be confirmed by ongoing trials.
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Affiliation(s)
- Katharina Beyer
- Department of General and Visceral Surgery, Charité University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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2
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Nagata T, Adachi Y, Taniguchi A, Kimura Y, Iitaka D, Iwata G, Yamaoka N. Prognostic impacts of categorized postoperative complications in surgery for gastric cancer. Asian J Surg 2023; 46:451-457. [PMID: 35691810 DOI: 10.1016/j.asjsur.2022.05.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/02/2022] [Accepted: 05/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Postoperative complications generally aggravate postoperative prognosis and are correlated with both cancer-specific death and death from other causes. METHODS Subjects were 197 patients who underwent gastrectomy at Kyoto Chubu Medical Center. Cancer-specific survival (CSS) and non-CSS (NCSS) were compared between cases with and without complications. Major complications were classified into C-com and N-com groups based on their prognostic impact on CSS and NCSS, respectively. Uni- and multivariate analyses were conducted using clinicopathological factors. RESULTS During the study period, 30 patients (15.2%) died from gastric cancer and 34 (17.3%) died from other causes. The incidence of postoperative complications was 16.8%. Sixteen patients with anastomosis leakage, pancreatic fistula, or organ/space surgical site infection had significantly poorer CSS, whereas 30 patients with pneumonia or passage obstruction had significantly poorer NCSS. These were defined as C-com and N-com cases, respectively. In the uni- and multivariate analyses, C-com was a significant prognostic factor for CSS (p = 0.002, p = 0.039) and N-com was a significant prognostic factor for NCSS (p < 0.0001, p = 0.004). C-reactive protein levels indicated intermediate and severe inflammation in N-com and C-com cases, respectively. CONCLUSION In N-com cases, surgical stress caused disruption of essential organ function, whereas damage in C-com cases occurred mostly in the abdominal cavity but was a risk for cancer regrowth. Thus, different postoperative complications worsen patient prognosis after gastrectomy in different ways. To optimize surgical outcomes, improved selection of treatment strategies for different complication types may be important.
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Affiliation(s)
- Tomoyuki Nagata
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan.
| | - Yuki Adachi
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
| | - Akihiro Taniguchi
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
| | - Yu Kimura
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
| | - Daisuke Iitaka
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
| | - George Iwata
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
| | - Nobuki Yamaoka
- Department of Surgery, Kyoto Chubu Medical Center, Nantan-city, Kyoto, Japan
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In Vitro and In Vivo Investigation on the Effectiveness of Alginate-Based Gastric Mucosal Protective Gel. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8287163. [PMID: 36060134 PMCID: PMC9433266 DOI: 10.1155/2022/8287163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 12/24/2022]
Abstract
Objective To investigate the feasibility and effectiveness of an alginate-based gastric mucosal protective gel on the gastric ulcer. Methods (1) In the physical protection model, after GES-1 cell attachment add the gel to transwell chamber, add different concentrations of HCl to the gel. Absorbance was measured to assess proliferation and images of the cells migrating into the wound were taken; then the migration rate of the cells was quantified by comparing images. (2) In the gastric ulcer model, excise the gastric mucosal of SD rats; the gel and fixative were applied on the artificial ulcer immediately. Dissect rats after 10 days, and calculate the wound healing rate and analyzed histology changes. Results The effect of hydrochloric acid on cells in the lower layer was significantly reduced after the use of gastric mucosal protection gel. The protective gel had an isolation effect on different concentrations of acid. A number of GES-1 were significantly higher than those in the control group at 24 h to 72 h (P < 0.01). The migration was observed compared with the control group. The average healing rate of ulcer in the gel group was about 50%, and the control group was about 30%. Inflammation occurred in all wound regions after ten days. In the gel group, inflammatory infiltration depth was lower than that of the control, and part of SD rats' new muscle layer appeared without inflammatory infiltration. The connective tissue proliferation promoted tissue repair. In the control group, necrosis marginal, mucosal hyperplasia, marginal lymphocyte aggregation, and bleeding were observed. Conclusion This novel gel mainly has an isolating and shielding effect to prevent the wound from being exposed to gastric acid for a long time, and it can reduce the inflammatory reaction on the wounds to promote the healing of the ulcer. The gastric mucosal protective gel cannot only promote the speed of wound healing but also improve the quality of wound healing.
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Hu Y, Yoon SS. Extent of gastrectomy and lymphadenectomy for gastric adenocarcinoma. Surg Oncol 2021; 40:101689. [PMID: 34839198 DOI: 10.1016/j.suronc.2021.101689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Abstract
Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well-established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This chapter outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed.
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Affiliation(s)
- Yinin Hu
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland Baltimore, Baltimore, MD, USA.
| | - Sam S Yoon
- Division of Surgical Oncology, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Cytoreductive Surgery for Peritoneal Carcinomatosis from Gastric Cancer: Technical Details. J Clin Med 2021; 10:jcm10225263. [PMID: 34830545 PMCID: PMC8619964 DOI: 10.3390/jcm10225263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022] Open
Abstract
Due to limited systemic treatment options, peritoneal carcinomatosis of gastric origin is still associated with a dismal outcome and is claimed a terminal disease. In the past, surgery had not been considered as a potential treatment option. However, there is emerging evidence that in selected patients, locoregional treatment modalities including cytoreductive surgery of peritoneal carcinomatosis can improve survival in patients with gastric cancer. These operative procedures are complex and challenging, and a high surgical expertise of the treating physician is necessary to prevent major postoperative morbidity and mortality with a delay of further systemic therapy. This review summarizes our current knowledge and personal experience regarding the techniques of cytoreductive surgery for peritoneal metastasis of gastric origin.
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Degiuli M, Reddavid R, Tomatis M, Ponti A, Morino M, Sasako M. D2 dissection improves disease-specific survival in advanced gastric cancer patients: 15-year follow-up results of the Italian Gastric Cancer Study Group D1 versus D2 randomised controlled trial. Eur J Cancer 2021; 150:10-22. [PMID: 33887514 DOI: 10.1016/j.ejca.2021.03.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/07/2021] [Accepted: 03/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The extended lymphadenectomy (D2) was recently introduced in several guidelines as the optimal treatment for gastric cancer, based only on the 15-year follow-up results of the Dutch randomised trial, while the British Medical Research Council (MRC) study failed to demonstrate a survival benefit over the more limited D1 dissection. The Italian Gastric Cancer Study Group randomised controlled trial (RCT) was also undertaken to compare D1 versus D2 gastrectomy, and a tendency to improve survival in patients with advanced resectable disease (pT > 1N+) was documented despite negative results in the entire patient population. Now we present the 15-year follow-up results of survival and gastric cancer-related mortality. METHODS Between June 1998 and December 2006, eligible patients with gastric cancer who signed the informed consent were randomised at 5 centres to either D1 or D2 gastrectomy. Intraoperative randomisation was implemented centrally by phone call. Primary outcome was overall survival (OS); secondary end-points were disease-specific survival, postoperative morbidity and mortality. Analyses were by intention to treat. Strict quality control measures for surgery, lymph node removal, pathology and patient follow-up were implemented and monitored. Registration number: ISRCTN11154654 (http://www.controlled-trials.com). FINDINGS A total of 267 eligible patients were assigned to either D1 (133 patients) or D2 (134) procedure. Median follow-up time was 16.76 years. Analyses were done both in overall patient population and in pT > 1N+. One hundred patients (38.5) were alive without recurrence. OS and disease-specific survival (DSS) were very high in both arms. In overall population, they were not different between D1 and D2 arm (51.3% vs. 46.8% and 65% vs. 67% respectively, p = 0.31 and p = 0.94). DSS was significantly higher after D2 in pT > 1N+ patients (29.4% vs. 51.4%, p = 0.035). OS and DSS were better after D1 in patients older than 70 years (p = 0.003 and p = 0.006). DSS was higher after D1 also in early stages (p = 0.01). INTERPRETATION After 15-year follow up, despite no relevant difference in overall population, DSS and gastric cancer-related mortality of patients with advanced disease and lymph node metastases are improved by D2 procedure. Further data available from this trial suggest that D1 procedure should be preferably used in older patients and in early disease. As accurate detection of advanced diseases can be currently provided by adequate preoperative workup in referral centres, D2 procedure should be recommended in these cases. FUNDING Piedmont Regional fund for Finalized Healthy Research Project, Application 2003 for data collection.
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Affiliation(s)
- M Degiuli
- University of Turin, Department of Oncology, San Luigi University Hospital, Surgical Oncology and Digestive Surgery Unit, Regione Gonzole 10, Orbassano, Turin, 10043, Italy.
| | - R Reddavid
- University of Turin, Department of Oncology, San Luigi University Hospital, Surgical Oncology and Digestive Surgery Unit, Regione Gonzole 10, Orbassano, Turin, 10043, Italy
| | - M Tomatis
- University of Turin, Department of Oncology, San Luigi University Hospital, Surgical Oncology and Digestive Surgery Unit, Regione Gonzole 10, Orbassano, Turin, 10043, Italy
| | - A Ponti
- CPO Piemonte, AOU Città Della Salute e della Scienza, Torino, Italy
| | - M Morino
- University of Turin, Department of Surgical Sciences, Turin, Italy
| | - M Sasako
- Department of Surgery, Yodogawa Christian Hospital, Yodogawa, Japan
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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: 1.3] [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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Griffin SM, Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Phillips AW. Evolution of gastrectomy for cancer over 30-years: Changes in presentation, management, and outcomes. Surgery 2021; 170:2-10. [PMID: 33674126 DOI: 10.1016/j.surg.2021.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/07/2020] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gastric cancer has seen a considerable change in management, and outcomes for the past 30 years. Historically, the overall prognosis has been regarded as poor. However, the use of multimodal treatment, and integration of enhanced recovery pathways have improved short and long-term outcomes. The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for gastric cancers over 30 years. METHODS Data from consecutive patients undergoing gastrectomy with curative intent for gastric adenocarcinoma between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies and outcomes were reviewed. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. RESULTS Between 1989 and 2018, 1,162 patients underwent gastrectomy with curative intent for cancer. Median age was 71 years (interquartile range, 63-76 years) and 763 (66%) were male. Patient presentation changed with epigastric discomfort now the most common presentation (67%). An improvement in overall complications from 54% to 35% (P = .006) and mortality from 8% to 1% (P < .001) was seen over the time period and overall survival improved from 28 months to 53 months (P < .001). CONCLUSION Both short-term and long-term outcomes have significantly improved over the 30 years studied. The reasons for this are multifactorial and include the use of perioperative chemotherapy, the introduction of an enhanced recovery pathway, and improved preoperative assessment of patients through a multidisciplinary input.
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Affiliation(s)
- S Michael Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK. https://twitter.com/smgriffin3
| | - Sivesh K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK. https://twitter.com/sivesh93
| | - Maziar Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK. https://twitter.com/Maz_surgery
| | - Shajahan Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Arul Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK. https://twitter.com/ArulImmanuel
| | - Nick Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne, UK; School of Medical Education, Newcastle University, Newcastle upon Tyne.
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Yoneda A, Kanetaka K, Fujita F, Takatsuki M, Kuroki T, Eguchi S. Outcomes Following Surgery for Gastric Cancer at a Single Institution: A 16-Year Experience. Int Surg 2021; 105:308-315. [DOI: 10.9738/intsurg-d-17-00093.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2025] Open
Abstract
Objective
We analyzed the cases of gastric cancer patients who underwent surgical treatment during the 16 years from 1997 to 2012 at our department to clarify these trends.
Methods
The subjects were 810 patients who underwent surgery for gastric cancer between 1997 and 2012. We divided the cases into the early-period group (1997–2006) treated before the introduction of laparoscopy, and the late-period group (2007–2012). We compared the clinicopathological factor and survival rates between the early- and late-period groups.
Results
The average patient age was higher in the late-period group than in the early-period group. Tumor localization showed an increased proportion in the U-region in the late period, and histological type in the late period showed a higher proportion of poorly differentiated cases. The cases receiving adjuvant chemotherapy increased in the late period. The five-year survival rate in the late-period group was shown to be equivalent to that in early-period group. Although the proportion of poorly differentiated cases was increased in late-period group, their survival rate was equivalent, probably because of the use of adjuvant chemotherapy.
Conclusions
Distinct characteristics were seen over the period of 16 years. It is important to continue the analysis of surgical outcomes to identify trends that need to be addressed.
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Affiliation(s)
- Akira Yoneda
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kengo Kanetaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Fumihiko Fujita
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tamotsu Kuroki
- Department of Surgery, National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Kulig P, Sierzega M, Pietruszka S, Pach R, Kołodziejczyk P, Kulig J, Richter P. Types and implications of abdominal fluid collections following gastric cancer surgery. Acta Chir Belg 2020; 120:315-320. [PMID: 31060443 DOI: 10.1080/00015458.2019.1615254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Little data are available for abscess and non-abscess abdominal fluid collections (AFCs) after gastric cancer surgery and their clinical implications. We sought to analyse the natural history of such collections in a population of patients subject to routine postoperative imaging.Methods: From 1996 to 2012, 1381 patients underwent gastric resections and routine postoperative monitoring with abdominal ultrasound. As a unit protocol, examinations were carried out in all patients prior to drain removal, immediately before discharge, and at follow-up visits.Results: AFCs were diagnosed in 134 (9.7%) patients after a median time from surgery of seven days (interquartile range (IQR) 5-11 days). Sixty-four of the 134 AFCs (48%) were asymptomatic and resolved spontaneously after a median follow-up of 26.5 days (IQR 14-91 days). Seventy (52%) AFCs required interventional drainage. A stepwise logistic regression model demonstrated that interventional treatment was much more likely among patients with enteric fistula (odds ratio (OR) 9.542, 95% CI 1.418-46.224, p=.003) and pancreatic fistula (OR 7.157, 95% CI 1.340-39.992, p=.012).Conclusions: About one half of AFCs after gastric surgery were asymptomatic and eventually resolved spontaneously without any intervention. However, the need for interventional drainage was significantly increased by coexisting pancreatic or enteric fistula.
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Affiliation(s)
- Piotr Kulig
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital Cracow, Krakow, Poland
| | - Marek Sierzega
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Szymon Pietruszka
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Pach
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Kołodziejczyk
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Jan Kulig
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Richter
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
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Kimura J, Okabayashi T, Sui K, Matsumoto T, Murokawa T, Iwata J, Morita S, Shimada Y. Feasibility of preserving the remnant stomach during distal pancreatectomy after distal gastrectomy. Surg Today 2020; 50:1394-1401. [PMID: 32358628 DOI: 10.1007/s00595-020-02016-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/19/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The safety and feasibility of preserving the remnant stomach during distal pancreatectomy (DP) in patients who have undergone distal gastrectomy (DG) remains unclear. METHODS A retrospective review of a prospectively maintained database was performed to identify patients who underwent DP. A propensity score-matched analysis was performed to match post-DG patients with control patients. RESULTS Among the 226 patients included in this study, 9 DP patients who had a history of DG were studied (4.0%). These nine patients in the DG group were matched to 45 patients in the control group. There were no significant differences in the incidence of postoperative morbidities, including postoperative pancreatic fistula rate or stomach-related complications. The hemoglobin A1C (HbA1c) levels in the DG group after surgery decreased to the normal range. CONCLUSION Our study suggested that the remnant stomach may be safely preserved when performing DP in patients with a history of DG with respect to short-term morbidities. However, there are some concerns about the long-term nutritional status in patients with a history of DG.
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Affiliation(s)
- Jiro Kimura
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan.
| | - Kenta Sui
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Takatsugu Matsumoto
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Takahiro Murokawa
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Sojiro Morita
- Department of Radiology, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
| | - Yasuhiro Shimada
- Department of Clinical Oncology, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi, 781-8555, Japan
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Short-term Outcomes of a Multicenter Randomized Controlled Trial Comparing Laparoscopic Distal Gastrectomy With D2 Lymphadenectomy to Open Distal Gastrectomy for Locally Advanced Gastric Cancer (KLASS-02-RCT). Ann Surg 2020; 270:983-991. [PMID: 30829698 DOI: 10.1097/sla.0000000000003217] [Citation(s) in RCA: 320] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the short-term outcomes of KLASS-02-RCT, a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy (LDG) with D2 lymphadenectomy with open distal gastrectomy (ODG). SUMMARY BACKGROUND DATA Although several benefits of laparoscopic gastric cancer surgery have been reported, strong evidence is still limited, especially in locally advanced gastric cancer which requires extensive lymph node dissection. METHODS Enrollment criteria included histologically confirmed cT2-4a and N0-1 gastric adenocarcinoma. Thirty-day morbidity, 90-day mortality, postoperative pain, and recovery were compared between LDG and ODG groups. RESULTS A total of 1050 patients were randomly assigned to LDG (n = 526) or ODG group (n = 524) between November 2011 and April 2015. After excluding patients who received bypass or no surgery, 1011 patients were analyzed as actual treatment group. Mean number of totally retrieved lymph nodes was similar in both groups (LDG = 46.6 vs ODG = 47.4, P = 0.451). Early morbidity rate was significantly lower after LDG (16.6%) than after ODG (24.1%; P = 0.003). Postoperative analgesics use and patients' reported pain score were significantly lower after LDG. First day of flatus was earlier after LDG (3.5 vs 3.7 d, P = 0.025) and postoperative hospital stay was shorter in LDG group (8.1 vs 9.3 d, P = 0.005). Ninety days' mortality rate was similar in both groups (LDG = 0.4% vs ODG = 0.6%, P = 0.682). CONCLUSIONS Laparoscopic distal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer shows benefits in terms of lower complication rate, faster recovery, and less pain compared with open surgery.
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Rausei S, Galli F, Lianos G, Rosa F, Cossu A, Biondi A, Martignoni F, Cananzi FCM, Fumagalli U, Alfieri S, Persiani R, Quagliuolo V, D'Ugo D, Rosati R. How Should We Measure the Quality of Lymphadenectomy for Gastric Cancer? Anatomical Versus Numerical Criterion. J Gastrointest Cancer 2019; 51:887-892. [PMID: 31691087 DOI: 10.1007/s12029-019-00321-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM To compare anatomical with numerical criterion to measure the quality of lymphadenectomy for gastric cancer. PATIENTS AND METHODS We analyzed 447 gastric cancer patients with resectable tumor stage (R0 resection) with at least 16 examined lymph nodes. RESULTS Of 447 patients, 82.6% underwent D2 lymphadenectomy for a median of total examined lymph nodes of 28. The 7-year disease-specific survival rate for the whole sample was 71.4%. Survival was significantly different between patients treated with D2 and D1 lymphadenectomy (77.4% versus 44.3%; p < 0.001) and between patients with total examined lymph nodes ≥ 28 and < 28 (74.5% versus 62.3%; p = 0.041). Anatomical criterion significantly differentiated 7-year survival in patients stratified according to a numerical parameter. CONCLUSION We should still consider the anatomical criterion as the best item to measure the quality of lymphadenectomy for gastric cancer.
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Affiliation(s)
- Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate, VA, Italy
| | - Federica Galli
- Department of Surgery, University of Insubria, Varese, Italy
| | - Georgios Lianos
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece.
| | - Fausto Rosa
- Division of Digestive Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy
| | - Andrea Cossu
- Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Biondi
- Division of General Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy
| | | | | | | | - Sergio Alfieri
- Division of Digestive Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy
| | - Roberto Persiani
- Division of General Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy
| | - Vittorio Quagliuolo
- Division of Surgical Oncology, Humanitas Clinical and Research Center, Rozzano, MI, Italy
| | - Domenico D'Ugo
- Division of General Surgery, Department of Surgical Sciences, Catholic University, Rome, Italy
| | - Riccardo Rosati
- Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy
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14
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Outcomes of Extended Lymphadenectomy for Gastroesophageal Carcinoma: A Large Western Series. J Am Coll Surg 2019; 228:879-891. [DOI: 10.1016/j.jamcollsurg.2019.02.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 12/12/2022]
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Mogal H, Fields R, Maithel SK, Votanopoulos K. In Patients with Localized and Resectable Gastric Cancer, What is the Optimal Extent of Lymph Node Dissection-D1 Versus D2 Versus D3? Ann Surg Oncol 2019; 26:2912-2932. [PMID: 31076930 DOI: 10.1245/s10434-019-07417-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite advances in the treatment of patients with gastric cancer, the debate over the optimal extent of lymphadenectomy continues. METHOD A review of the classification, rationale for, and boundaries of lymphadenectomy is presented. A review of the available literature comparing D1 versus D2 versus D3 lymphadenectomy was performed and included randomized controlled trials, and prospective and retrospective comparative and non-comparative studies. RESULTS Earlier studies demonstrated increased morbidity with D2 compared with D1 lymphadenectomy, with no significant survival benefit. More recent studies have demonstrated survival benefit of a pancreas and spleen-sparing D2 lymphadenectomy in patients with advanced, node-positive tumors. Para-aortic/D3 dissections contribute to increased morbidity, with no survival benefit. CONCLUSIONS In patients with resectable gastric adenocarcinoma, a D2 lymph node dissection preserving the pancreas and spleen should be considered standard for optimal staging and treatment, provided it is performed by surgeons with sufficient expertise. Extended lymph node dissections beyond D2 should not be routinely performed as it has been shown to have increased morbidity, with no improvement in outcomes. While systemic chemotherapy should be considered standard in patients undergoing D2 lymphadenectomy, the role of adjuvant radiation continues to evolve.
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Affiliation(s)
- Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Ryan Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
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16
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Fugazzola P, Ansaloni L, Sartelli M, Catena F, Cicuttin E, Leandro G, De' Angelis GL, Gaiani F, Di Mario F, Tomasoni M, Coccolini F. Advanced gastric cancer: the value of surgery. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:110-116. [PMID: 30561428 PMCID: PMC6502221 DOI: 10.23750/abm.v89i8-s.7897] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Indexed: 02/06/2023]
Abstract
Gastric cancer is a common disease with high mortality. The definition of advanced gastric cancer is still debated. Radical surgery associated to appropriate systemic and intra-abdominal chemotherapy is the gold standard treatment. In presence of peritoneal carcinosis, reaching a complete cytoreduction is the key to achieve long-term survival. Adequate lymphadenectomy is also fundamental. Conversion therapy could be applied to selected IV stage patients. No definitive evidences exist regarding the oncological and surgical superiority of mini-invasive approaches over the classical open techniques.
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Affiliation(s)
- Paola Fugazzola
- Emergency, General and Trauma Surgery dept., Bufalini hospital, Cesena, Italy.
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17
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Reddavid R, Sofia S, Chiaro P, Colli F, Trapani R, Esposito L, Solej M, Degiuli M. Neoadjuvant chemotherapy for gastric cancer. Is it a must or a fake? World J Gastroenterol 2018; 24:274-289. [PMID: 29375213 PMCID: PMC5768946 DOI: 10.3748/wjg.v24.i2.274] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 12/13/2017] [Accepted: 12/20/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the neoadjuvant chemotherapy (NAC) effect on the survival of patients with proper stomach cancer submitted to D2 gastrectomy.
METHODS We proceeded to a review of the literature with PubMed, Embase, ASCO and ESMO meeting abstracts as well as computerized use of the Cochrane Library for randomized controlled trials (RCTs) comparing NAC followed by surgery (NAC + S) with surgery alone (SA) for gastric cancer (GC). The primary outcome was the overall survival rate. Secondary outcomes were the site of the primary tumor, extension of node dissection according to Japanese Gastric Cancer Association (JGCA) performed in both arms, disease-specific (DSS) and disease-free survival (DFS) rates, clinical and pathological response rates and resectability rates after perioperative treatment.
RESULTS We identified a total of 16 randomized controlled trials comparing NAC + S (n = 1089) with SA (n = 973) published in the period from January 1993 - March 2017. Only 6 of these studies were well-designed, structured trials in which the type of lymph node (LN) dissection performed or at least suggested in the trial protocol was reported. Two out of three of the RCTs with D2 lymphadenectomy performed in almost all cases failed to show survival benefit in the NAC arm. In the third RCT, the survival rate was not even reported, and the primary end points were the clinical outcomes of surgery with and without NAC. In the remaining three RCTs, D2 lymph node dissection was performed in less than 50% of cases or only recommended in the “Study Treatment” protocol without any description in the results of the procedure really perfomed. In one of the two studies, the benefit of NAC was evident only for esophagogastric junction (EGJ) cancers. In the second study, there was no overall survival benefit of NAC. In the last trial, which documented a survival benefit for the NAC arm, the chemotherapy effect was mostly evident for EGJ cancer, and more than one-fourth of patients did not have a proper stomach cancer. Additionally, several patients did not receive resectional surgery. Furthermore, the survival rates of international reference centers that provide adequate surgery for homogeneous stomach cancer patients’ populations are even higher than the survival rates reported after NAC followed by incomplete surgery.
CONCLUSION NAC for GC has been rapidly introduced in international western guidelines without an evidence-based medicine-related demonstration of its efficacy for a homogeneous population of patients with only stomach tumors submitted to adequate surgery following JGCA guidelines with extended (D2) LN dissection. Additional larger sample-size multicentre RCTs comparing the newer NAC regimens including molecular therapies followed by adequate extended surgery with surgery alone are needed.
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Affiliation(s)
- Rossella Reddavid
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
| | - Silvia Sofia
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
| | - Paolo Chiaro
- Department of Surgical Sciences, Digestive and Oncological Surgery, University of Turin, Molinette Hospital, Turin 10126, Italy
| | - Fabio Colli
- Department of Surgical Sciences, Digestive and Oncological Surgery, University of Turin, Molinette Hospital, Turin 10126, Italy
| | - Renza Trapani
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
| | - Laura Esposito
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
| | - Mario Solej
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
| | - Maurizio Degiuli
- Surgical Oncology and Digestive Surgery, Department of Oncology, University of Turin, San Luigi University Hospital, Orbassano, Turin 10049, Italy
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18
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Nakagawa M, Tomii C, Inokuchi M, Otsuki S, Kojima K. Feasibility of a Clinical Pathway With Early Oral Intake and Discharge for Laparoscopic Gastrectomy. Scand J Surg 2017; 107:218-223. [PMID: 29268666 DOI: 10.1177/1457496917748228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Although some studies have reported the safety of early oral intake after gastrectomy, it still remains controversial. This study focused on the feasibility of a clinical pathway with early oral intake and discharge setting for exclusively laparoscopic distal gastrectomy. MATERIALS AND METHODS A clinical pathway was applied to 403 patients until December 2014. In the protocol, patients are allowed to take a sip of water and a soft diet on the first and second days after the operation, respectively, and the discharge day is set as the fifth to seventh day after the operation. Clinicopathological variables were prospectively collected, and risk factors for discharge variances were analyzed. RESULTS The completion rate of the clinical pathway was 76.9%. There were five re-admissions (1.2%). The overall morbidity rate was 18% ( n = 72), and major complications (Clavien-Dindo IIIa or greater) occurred in 13 patients (3%). Complications were the causes for discharge variances in 68 cases (73%), while the attending surgeons' judgment was the cause in 25 cases (27%). On multivariate analysis, age (odds ratio = 2.23, 95% confidence interval = 1.38-3.60, p = 0.001) and operative time (odds ratio = 2.38, 95% confidence interval = 1.45-3.98, p = 0.001) were independent risk factors for discharge variances. CONCLUSION A high completion rate of a clinical pathway with early oral intake and discharge setting for laparoscopic distal gastrectomy was achievable with an acceptably low re-admission rate. Laparoscopic distal gastrectomy is recommended as a first step for a clinical pathway with an early oral intake and discharge protocol.
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Affiliation(s)
- M Nakagawa
- 1 Department of Gastric Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - C Tomii
- 1 Department of Gastric Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - M Inokuchi
- 1 Department of Gastric Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Otsuki
- 1 Department of Gastric Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - K Kojima
- 2 Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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Badgwell B, Das P, Ajani J. Treatment of localized gastric and gastroesophageal adenocarcinoma: the role of accurate staging and preoperative therapy. J Hematol Oncol 2017; 10:149. [PMID: 28810883 PMCID: PMC5558742 DOI: 10.1186/s13045-017-0517-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/09/2017] [Indexed: 01/11/2023] Open
Abstract
Gastric cancer is the third most common cause of cancer death worldwide, although it is not in the top 10 causes of cancer death in Northern America. Due to clear differences in incidence, screening, risk factors, tumor biology, and treatment between gastric cancers from Eastern and Western countries, our treatment is primarily guided by trials from Western countries. Patients undergo an extensive staging evaluation including high-quality CT imaging, endoscopic ultrasound, and diagnostic laparoscopy with peritoneal washings for cytology. Patients are presented in multidisciplinary conference with input from medical, radiation, and surgical oncology, in addition to further evaluation of existing studies and biopsy results by diagnostic radiology and pathology colleagues. Due to the well-documented difficulty in tolerating postoperative therapy, patients are frequently treated with preoperative chemotherapy and chemoradiotherapy. Extended lymph node (D2) dissection is routinely performed during subtotal or total gastrectomy. Ongoing trials in Western populations comparing preoperative chemotherapy to chemoradiotherapy will help inform the decision regarding the optimal treatment for patients with resectable gastric cancer. Additional studies are needed to identify predictors of treatment response to identify the optimal preoperative or perioperative approach. As peritoneal disease is the most common site of recurrence, studies are also urgently needed for more accurate methods of detecting peritoneal disease at diagnosis, and also investigating potential treatment modalities such as hyperthermic intraperitoneal chemotherapy.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, The University of Texas, Unit 1484, MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Prajnan Das
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer Ajani
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features. Abdom Radiol (NY) 2017; 42:2054-2068. [PMID: 28493073 DOI: 10.1007/s00261-017-1165-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.
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21
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Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA? World J Surg Oncol 2017; 15:135. [PMID: 28716043 PMCID: PMC5514466 DOI: 10.1186/s12957-017-1204-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/08/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Gastric cancer remains a formidable treatment challenge. For decades, treatment consisted mostly of surgical intervention for this deadly disease. With improvements in the multi-disciplinary management of solid organ malignancies, the approach to this disease is being stepwise refined. MAIN BODY One of the prevalent controversies in the surgical management of gastric cancer rests on the need for adequate harvesting of lymph nodes. For decades, lymph node dissection is regarded as a staging technique useful in only upstaging the disease. The adoption of D2 lymphadenectomy has been particularly slow to mature. But with prevailing data from Asia consistently demonstrating a survival benefit from lymphadenectomy, it calls into question the notion of lymphadenectomy as being solely a staging procedure. CONCLUSIONS As gastric resection techniques are being better defined in western countries and surgical morbidities lowered on its execution, D2 lymphadenectomy is becoming more accepted as the new standard in the management of gastric cancer.
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22
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Taki T, Hoya Y, Watanabe A, Nakayoshi T, Okamoto T, Sekine H, Mitsumori N, Yanaga K. Usefulness of chemoradiotherapy for inoperable gastric cancer. Ann R Coll Surg Engl 2016; 99:332-336. [PMID: 27659357 DOI: 10.1308/rcsann.2016.0305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Introduction Radiotherapy is not commonly used for the treatment of gastric cancer in Japan, where surgery is the standard local treatment. We report the results of chemoradiotherapy in patients with advanced or recurrent gastric cancer which was deemed difficult to treat surgically. Methods Twenty-one patients with gastric cancer (including sixteen with advanced/recurrent gastric cancer and five with poor general condition) underwent chemo-radiotherapy, for whom the therapeutic efficacy, toxicity and survival period were analysed. Results The tumour response to chemoradiotherapy was categorised as complete, partial, stable or progressive in 5, 9, 3, and 4 patients, respectively, with an overall response rate of 67%. No serious complications such as gastrointestinal perforation or bleeding occurred, and no cardiac, hepatic or renal dysfunction developed during the follow-up period. The mean survival time was 19.8 months (range, 3-51 months). One patient died of another disease, 18 died of primary cancer and the cause of death was unknown in 2 patients. Conclusions Chemoradiotherapy appears to be an effective treatment for localised gastric cancer without distant metastases, but further studies are needed to determine the indications for chemoradiotherapy and late adverse effects, as well as the chemotherapy regimens to be used.
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Affiliation(s)
- T Taki
- Department of Surgery, Jikei University Daisan Hospital , Tokyo , Japan
| | - Y Hoya
- Department of Surgery, Jikei University Daisan Hospital , Tokyo , Japan
| | - A Watanabe
- Department of Surgery, Jikei University Daisan Hospital , Tokyo , Japan
| | - T Nakayoshi
- Department of Surgery, Jikei University Daisan Hospital , Tokyo , Japan
| | - T Okamoto
- Department of Surgery, Jikei University Daisan Hospital , Tokyo , Japan
| | - H Sekine
- Department of Radiology, Jikei University Daisan Hospital , Tokyo , Japan
| | - N Mitsumori
- Department of Radiology, Jikei University Daisan Hospital , Tokyo , Japan
| | - K Yanaga
- Department of Surgery, Jikei University School of Medicine , Tokyo , Japan
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23
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Randle RW, Swords DS, Levine EA, Fino NF, Squires MH, Poultsides G, Fields RC, Bloomston M, Weber SM, Pawlik TM, Jin LX, Spolverato G, Schmidt C, Worhunsky D, Cho CS, Maithel SK, Votanopoulos KI. Optimal extent of lymphadenectomy for gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative. J Surg Oncol 2016; 113:750-5. [PMID: 26996496 DOI: 10.1002/jso.24227] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/09/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The optimal extent of lymphadenectomy in the treatment of gastric adenocarcinoma is debated. We compared gastrectomy outcomes following limited (D1) or extended (D2) lymphadenectomy. METHODS Using the multi-institutional US Gastric Cancer Collaborative database, we reviewed the morbidity, mortality, recurrence, and overall survival (OS) of patients receiving D1 or D2 lymphadenectomies. RESULTS Between 2000 and 2012, 266 and 461 patients received a D1 and D2 lymphadenectomy, respectively. ASA class, mean number of comorbidities, grade, and stage were similar between groups. While major morbidity was similar (P = 0.85), mortality was worse for those receiving a D1 lymphadenectomy (4.9% vs. 1.3%, P = 0.004). D2 lymphadenectomy was associated with improved median OS in stage I (4.7 years for D1 vs. not reached for D2, P = 0.003), stage II (3.6 years for D1 vs. 6.3 for D2, P = 0.42), and stage III patients (1.3 years for D1 vs. 2.1 for D2, P = 0.01). After adjusting for predictors of OS, D2 lymphadenectomy remained a significant predictor of improved survival (HR 1.5, 95%CI 1.1-2.0, P = 0.008). CONCLUSIONS D2 lymphadenectomy can be performed without increased risk of morbidity and mortality. Additionally, D2 lymphadenectomy is associated with improved survival especially in early stages, and should be considered for gastric adenocarcinoma patients. J. Surg. Oncol. 2016;113:750-755. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Reese W Randle
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Douglas S Swords
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward A Levine
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora F Fino
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Mark Bloomston
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy M Pawlik
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Gaya Spolverato
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - David Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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24
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Pennell CP, Hirst AD, Campbell WB, Sood A, Agha RA, Barkun JST, McCulloch P. Practical guide to the Idea, Development and Exploration stages of the IDEAL Framework and Recommendations. Br J Surg 2016; 103:607-15. [PMID: 26865013 DOI: 10.1002/bjs.10115] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/11/2015] [Accepted: 12/21/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Evaluation of new surgical procedures is a complex process challenged by evolution of technique, operator learning curves, the possibility of variable procedural quality, and strong treatment preferences among patients and clinicians. Preliminary studies that address these issues are needed to prepare for a successful randomized trial. The IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) Framework and Recommendations provide an integrated step-by-step evaluation pathway that can help investigators achieve this. METHODS A practical guide was developed for investigators evaluating new surgical interventions in the earlier phases before a randomized trial (corresponding to stages 1, 2a and 2b of the IDEAL Framework). The examples and practical tips included were chosen and agreed upon by consensus among authors with experience either in designing and conducting IDEAL format studies, or in helping others to design such studies. They address the most common challenges encountered by authors attempting to follow the IDEAL Recommendations. RESULTS A decision aid has been created to help identify the IDEAL stage of an innovation from literature reports, with advice on how to design and report the IDEAL study formats discussed, along with the ethical and scientific rationale for specific recommendations. CONCLUSION The guide helps readers and researchers to understand and implement the IDEAL Framework and Recommendations to improve the quality of evidence supporting surgical innovation.
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Affiliation(s)
- C P Pennell
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - A D Hirst
- IDEAL Collaboration, Nuffield Department of Surgical Science, Oxford, UK
| | - W B Campbell
- Interventional Procedures and Medical Technologies Advisory Committees, National Institute for Health and Care Excellence, London, UK
| | - A Sood
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - R A Agha
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J S T Barkun
- Department of Surgery, Division of Hepatobiliary and Transplant Surgery, McGill University Health Centre, Royal Victoria Hospital. Montreal, Quebec, Canada
| | - P McCulloch
- IDEAL Collaboration, Nuffield Department of Surgical Science, Oxford, UK
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25
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Abstract
Gastric cancer remains one of the most important malignancies worldwide in terms of incidence and mortality. The treatment is based on the combination of local surgery and radiation therapy as well as systemic chemotherapy and targeted molecules. Fluoropyrimidines and particularly 5-fluorouracil (FU) represent still the backbone for gastric cancer chemotherapy and new molecular versions of this molecule have been brought to clinical practice in order to improve benefits and reduce adverse effects. S-1 is an oral prodrug of 5-FU, which has demonstrated high effectiveness for gastric cancer treatment and a favorable safety profile. Currently, there are geographic differences in the treatment of gastric cancer and in the use of S-1, which is a mainstay of gastric cancer management in Eastern countries, but is not part of the standard care in the rest of the world. In this review, we gathered data from phase I, II, and III trials of S-1 in gastric cancer, in order to define its real benefit-risk ratio and assess whether geographic differences in S-1 use are justified by unchangeable factors.
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Affiliation(s)
- Eriseld Krasniqi
- Department of Systems Medicine, Medical Oncology, University of Rome 'Tor Vergata', Tor Vergata Clinical Center, Rome, Italy
| | - Stefania Pellicori
- Department of Systems Medicine, Medical Oncology, University of Rome 'Tor Vergata', Tor Vergata Clinical Center, Rome, Italy
| | - Vincenzo Formica
- Department of Systems Medicine, Medical Oncology, University of Rome 'Tor Vergata', Tor Vergata Clinical Center, Rome, Italy
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Laparoscopic Total Gastrectomy in the Western Patient Population: Tips, Techniques, and Evidence-based Practice. Surg Laparosc Endosc Percutan Tech 2015; 25:455-61. [PMID: 26492457 DOI: 10.1097/sle.0000000000000210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the second most common malignancy worldwide, and surgical resection is the only curative treatment. Traditionally, open total gastrectomy has been the procedure of choice for large and proximal carcinomas. Over the past decade, however, laparoscopic gastrectomy has emerged and an oncologically safe and feasible alternative to open surgery, and its use has become particularly widespread in Japan and Korea. Patients in the United States have important biological and anatomic distinctions from East Asian patients, and these become important factors when considering minimally invasive resection techniques. The goal of this paper is to describe the technique we have developed for laparoscopic total gastrectomy in our 10-year experience with a western patient population.
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Badgwell B, Ajani J, Blum M, Ho L, Fournier K, Chiang YJ, Matamoros A, Das P, Mansfield P. Postoperative Morbidity and Mortality Rates are Not Increased for Patients with Gastric and Gastroesophageal Cancer Who Undergo Preoperative Chemoradiation Therapy. Ann Surg Oncol 2015; 23:156-62. [PMID: 26059652 DOI: 10.1245/s10434-015-4643-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aimed to determine whether postoperative morbidity and mortality rates increased after preoperative chemoradiation in patients who underwent gastrectomy. METHODS The medical records of 7404 patients with gastric or gastroesophageal cancer seen from January 1995 to August 2012 were reviewed to identify patients who underwent gastrectomy. χ (2) and logistic regression analysis were used to determine differences in the 90-day postoperative morbidity and mortality rates of patients who underwent upfront surgery (SURG), preoperative chemotherapy (CHEMO), or preoperative chemoradiation (CHEMOXRT). RESULTS Of the 500 patients included in this study, 200 underwent SURG, 65 had CHEMO, and 235 had CHEMOXRT. Respectively, 33, 43, and 58 % of these patients underwent total gastrectomy (p < 0.01). Resection of other organs was performed respectively in 19, 26, and 23 % of the patients (p = 0.37). Minor complications within 90 days (Clavien-Dindo 1 or 2) occurred for 41 % of the SURG patients, 43 % of the CHEMO patients, and 45 % of the CHEMOXRT patients (p = 0.68). Major complications or death within 90 days (Clavien-Dindo 3, 4, or 5) occurred for 21, 28, and 29 % of the patients, respectively (p = 0.15). The 90-day mortality (Clavien-Dindo 5) rates were 2 % for the SURG patients, 6 % for the CHEMO patients, and 3 % for the CHEMOXRT patients (p = 0.25). The median hospital stays were respectively 12, 12, and 13 days (p = 0.09). In the multivariate analysis, male sex, gastroesophageal junction cancer, total gastrectomy, and resection of other organs were associated with increased major morbidity and mortality rates, whereas preoperative therapy was not. CONCLUSIONS The CHEMOXRT patients had postoperative morbidity and mortality rates similar to those for the SURG and CHEMO patients.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jaffer Ajani
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linus Ho
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Fournier
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aurelio Matamoros
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hur H, Lee HY, Lee HJ, Kim MC, Hyung WJ, Park YK, Kim W, Han SU. Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial. BMC Cancer 2015; 15:355. [PMID: 25939684 PMCID: PMC4432816 DOI: 10.1186/s12885-015-1365-z] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 04/24/2015] [Indexed: 02/07/2023] Open
Abstract
Background Despite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial (RCT) to compare laparoscopic and open D2 lymphadenectomy for patients with locally AGC. Here, we introduce the protocol of this clinical trial. Methods/design This trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2–cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial. Discussion This clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure. Trial registration ClinicalTrial.gov, NCT01456598.
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Affiliation(s)
- Hoon Hur
- Department of Surgery, Ajou University Medical Center, Ajou University School of Medicine, 206 Worldcup-ro, Youngtong-gu, Suwon, 443-749, Korea.
| | - Hyun Yong Lee
- Clinical Trial Center, Ajou University Medical Center, Ajou University School of Medicine, Suwon, 443-749, Korea.
| | - Hyuk-Joon Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, 110-799, Korea.
| | - Min Chan Kim
- Department of Surgery, Dong-A University College of Medicine, Busan, 602-715, Korea.
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, 120-749, Korea.
| | - Young Kyu Park
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, 519-763, Korea.
| | - Wook Kim
- Department of Surgery, The Catholic University, Yeouido St. Mary's Hospital, Seoul, 150-713, Korea.
| | - Sang-Uk Han
- Department of Surgery, Ajou University Medical Center, Ajou University School of Medicine, 206 Worldcup-ro, Youngtong-gu, Suwon, 443-749, Korea.
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Badgwell B, Blum M, Estrella J, Chiang YJ, Das P, Matamoros A, Fournier K, Mansfield P, Ajani J. Predictors of Survival in Patients with Resectable Gastric Cancer Treated with Preoperative Chemoradiation Therapy and Gastrectomy. J Am Coll Surg 2015; 221:83-90. [PMID: 26002780 DOI: 10.1016/j.jamcollsurg.2015.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/19/2015] [Accepted: 04/06/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND The purpose of this study was to determine the overall survival (OS) of patients with resectable gastric cancer treated with preoperative chemoradiation therapy and gastrectomy. STUDY DESIGN The medical records of patients with gastric adenocarcinoma presenting to our institution (January 1995 to August 2012) were reviewed to identify patients who underwent diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy. Associations between various clinicopathologic factors and OS were examined with Cox proportional hazards models. RESULTS Of 192 patients who met inclusion criteria, 103 (54%) required total gastrectomy. One hundred sixty-eight patients (88%) had an extended lymph node dissection, 26 (14%) had resection of adjacent organs, and 178 (93%) had an R0 resection. Median follow-up time for surviving patients was 4.2 years. Median OS for all patients was 5.8 years, and 5-year OS rate was 56%. Multivariable Cox regression model results identified variables associated with diminished OS including age ≥ 65 years (hazard ratio [HR] 1.62; 95% CI 1.05 to 2.51), male sex (HR 1.76; 95% CI 1.13 to 2.74), adjacent organ resection (HR 1.97; 95% CI 1.16 to 3.35), R1 status (HR 2.29; 95% CI 1.17 to 4.48), pathologic N1 stage (HR 1.92; 95% CI 1.24 to 2.98), N2 stage (HR 2.58; 95% CI 1.01 to 6.58), and N3 stage (HR 6.54; 95% CI 2.69 to 15.93). Five-year OS rates for patients with pathologic N0, N1, N2, and N3 disease were 67%, 42%, 43%, and 0%, respectively. CONCLUSIONS Patients with gastric cancer who undergo diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy have a high frequency of obtaining an R0 resection and excellent OS rates. Nodal status after surgery remains an important determinant of OS.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Mariela Blum
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeannelyn Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aurelio Matamoros
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer Ajani
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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30
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Managing Early and Late Postoperative Complications Following Gastric Surgery. Gastric Cancer 2015. [DOI: 10.1007/978-3-319-15826-6_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Song JX, Tu XH, Wang B, Lin C, Zhang ZZ, Lin LY, Wang L. "Fast track" rehabilitation after gastric cancer resection: experience with 80 consecutive cases. BMC Gastroenterol 2014; 14:147. [PMID: 25135360 PMCID: PMC4236561 DOI: 10.1186/1471-230x-14-147] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 08/08/2014] [Indexed: 12/21/2022] Open
Abstract
Background To evaluate the safety, efficacy and outcomes of fast-track rehabilitation applied to gastric cancer proximal, distal and total gastrectomy. Methods Eighty consecutive patients undergoing gastric cancer resection performed by a single surgeon, received perioperative multimodal rehabilitation. Demographic and operative data, gastrointestinal function, postoperative hospital stays, surgical and general complications and mortality were assessed prospectively. Results Of the 80 patients (mean age 56.3 years), 10 (12.5%) received proximal subtotal gastrectomy (Billroth I), 38 (47.5%) received distal (Billroth II), and 32 (40%) received total gastrectomy (Roux-en-Y). Mean operative time was 104.9 minutes and intraoperative blood loss was 281.9 ml. Time to first flatus was 2.8 ± 0.5 postoperative days. Patients were discharged at a mean of 5.3 ± 2.2 postoperative days; 30-day readmission rate was 3.8%. In-hospital mortality was 0%; general and surgical complications were both 5%. Conclusions Fast-track multimodal rehabilitation is feasible and safe in patients undergoing gastric cancer resection and may reduce time to first flatus and postoperative hospital stays.
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Affiliation(s)
| | | | | | | | | | | | - Lie Wang
- Department of General Surgery, Fuzhou General Hospital of Nanjing Military Command, No, 156 North Xi'erhuan Road, Fuzhou 350025, Fujian, China.
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Lee KG, Lee HJ, Yang JY, Oh SY, Bard S, Suh YS, Kong SH, Yang HK. Risk factors associated with complication following gastrectomy for gastric cancer: retrospective analysis of prospectively collected data based on the Clavien-Dindo system. J Gastrointest Surg 2014; 18:1269-77. [PMID: 24820136 DOI: 10.1007/s11605-014-2525-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/07/2014] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Kyung-Goo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Abstract
Much debate still exists regarding the appropriate extent of lymphadenectomy for gastric adenocarcinoma. In high incidence countries in Eastern Asia, more extensive (e.g. D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity (<20 %) and mortality (<1 %). In United States and Western Europe, where the incidence of gastric adenocarcinoma is much lower, the majority of patients are treated at non-referral centers with less extensive (e.g. D1 or D0) lymphadenectomy. This symposium article first reviews early studies that led to recommendations for less extensive lymphadenectomy. Two large prospective, randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity (43-46 %) and high mortality rates (10-13 %) in the D2 group. We then discuss more contemporary studies that support more extensive lymphadenectomy with a minimum of 16 lymph nodes for adequate staging. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. A prospective, randomized trial from Taiwan found a survival benefit of more extensive lymphadenectomies, and another randomized trial from Japan found adding dissection of para-aortic nodes to a D2 lymphadenectomy did not improve survival. Western surgeons have increasingly accepted the importance of performing more than a D1 node dissection, and Eastern surgeons are accepting that more than a D2 node dissection does not improve survival and increases morbidity. Thus both Eastern and Western approaches are favoring D2 lymphadenectomy as a standard, and on this topic we appear to be harmonizing.
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Affiliation(s)
- Vivian E Strong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, H-1217, New York, NY 10065, USA.
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Kim YD, Kim MC, Kim KH, Kim YM, Jung GJ. Readmissions following elective radical total gastrectomy for early gastric cancer: a case-controlled study. Int J Surg 2014; 12:200-4. [PMID: 24406263 DOI: 10.1016/j.ijsu.2013.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 12/13/2013] [Accepted: 12/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Readmission after gastrectomy is one of the factors that reflect quality of life. Therefore, we analyzed the several factors related to readmissions after total gastrectomy for early gastric cancer. METHODS From January 2002 through December 2009, 102 consecutive patients who underwent radical total gastrectomy for early gastric cancer were enrolled in this study. We evaluated the incidence, cause, time point, and type of treatment for readmission after discharge; we compared the readmission and non-readmission groups in regard to clinicopathologic features and postoperative outcomes. RESULTS The readmission rate during the five years after total gastrectomy was 22 of 102 (21.6%). The most common cause for readmission was esophagojejunostomy stricture (5 cases). The treatment given for 31 readmissions included 23 conservative therapies, 3 radiologic or endoscopic interventions, and 5 re-operations. No significant differences were detected in the clinicopathologic feature, postoperative outcomes, or 5-year survival rates between the readmission and non-readmission group. No specific risk factor was found to be associated with readmission. CONCLUSION Although we could not determine a specific risk factor associated with readmission after radical total gastrectomy, prevention of readmission by evaluating the causes and treatments after radical total gastrectomy can improve the patient's quality of life.
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Affiliation(s)
- Yong-Deok Kim
- Dong-A University College of Medicine, Busan 602-715, Republic of Korea
| | - Min-Chan Kim
- Dong-A University College of Medicine, Busan 602-715, Republic of Korea; Department of Surgery, Dong-A University College of Medicine, Busan 602-715, Republic of Korea.
| | - Ki-Han Kim
- Dong-A University College of Medicine, Busan 602-715, Republic of Korea; Department of Surgery, Dong-A University College of Medicine, Busan 602-715, Republic of Korea
| | - Yoo-Min Kim
- Department of Surgery, Dong-A University College of Medicine, Busan 602-715, Republic of Korea
| | - Ghap-Joong Jung
- Dong-A University College of Medicine, Busan 602-715, Republic of Korea; Department of Surgery, Dong-A University College of Medicine, Busan 602-715, Republic of Korea
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35
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Montgomery M, Fukuhara S, Karpeh M, Brower S. Evidence-based review of the management of early gastric cancer. Gastroenterol Rep (Oxf) 2013; 1:105-12. [PMID: 24759815 PMCID: PMC3938004 DOI: 10.1093/gastro/got016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Although standard gastrectomy remains the most definitive locoregional treatment for early gastric cancer, it carries significant perioperative morbidities. Surgical gastrectomy for resection of lymph nodes is not always required and endoscopic resection may be a treatment option for patients at negligible risk of lymph node metastasis. Furthermore, the criteria for endoscopic resection are expanding, along with the development of new technology, in both Eastern and western countries with high prevalence of early gastric cancer, where studies for endoscopic treatment modalities have been conducted. Within such a trend, however, it should be emphasized that early gastric cancer needs to be treated cautiously, especially in western countries, as several studies suggest that there may be differences in tumor biology and aggressiveness between Asian and non-Asian populations.
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Affiliation(s)
| | | | | | - Steven Brower
- Department of Surgery, Beth Israel Medical Center, New York NY, USA
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36
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Blakely AM, Miner TJ. Surgical considerations in the treatment of gastric cancer. Gastroenterol Clin North Am 2013; 42:337-57. [PMID: 23639644 PMCID: PMC4467541 DOI: 10.1016/j.gtc.2013.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.
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Affiliation(s)
- Andrew M. Blakely
- Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 4, Providence, RI 02903, USA
| | - Thomas J. Miner
- Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA,Corresponding author.
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37
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Blakely AM, Miner TJ. Surgical considerations in the treatment of gastric cancer. Gastroenterol Clin North Am 2013. [PMID: 23639644 DOI: 10.1016/j.gtc.2013.01.010.surgical] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.
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Affiliation(s)
- Andrew M Blakely
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
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38
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Surgical outcomes and clinicopathological characteristics of patients who underwent potentially noncurative endoscopic resection for gastric cancer: a report of a single-center experience. Gastroenterol Res Pract 2013; 2013:427405. [PMID: 23762035 PMCID: PMC3670513 DOI: 10.1155/2013/427405] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/07/2013] [Indexed: 02/08/2023] Open
Abstract
Background. Standard treatment of early gastric cancer (EGC) after endoscopic resection with risk factors of nodal metastases and incomplete resection is controversial. We investigated optimal management for the patients with potentially noncurative EGC after endoscopic resection. Methods. We retrospectively examined clinicopathological data and surgical outcomes of all patients with clinically solitary gastric adenocarcinoma who underwent curative surgery after a single peroral endoscopic resection at the Digestive Disease Center of Showa University Northern Yokohama Hospital between April 2001 and December 2012. Fisher's exact test was used for univariate analysis. For multivariate analysis, stepwise multiple linear regression was used to identify independent predictors related to lymph node metastasis and remnant of primary tumor. Results. A total of 41 patients were studied. Four patients (9.8%) had lymph node metastases. Primary tumors remained in 6 patients (14.6%). Only venous invasion was statistically significant to lymph node metastasis (P = 0.017). With respect to remnant of the primary tumor, pT1b2 tumor invasion (P = 0.015) and horizontal margin (P = 0.013) were statistically significant. Conclusions. Surgery with limited lymphadenectomy is recommended for tumors with venous invasion or pT1b2 tumor invasion, and additional endoscopic resection may be allowed for tumors with horizontal involvement.
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40
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Jiang L, Yang KH, Guan QL, Zhao P, Chen Y, Tian JH. Survival and recurrence free benefits with different lymphadenectomy for resectable gastric cancer: a meta-analysis. J Surg Oncol 2013; 107:807-14. [PMID: 23512524 DOI: 10.1002/jso.23325] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 01/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective of the present meta-analysis was to estimate the magnitude of survival and recurrence free benefits from different lymphadenectomy in patients with resectable gastric cancer. METHODS A comprehensive search was performed for original studies published from their inception to 2012. Two reviewers independently assessed search results, methodological quality, and data extraction of included studies. Results regarding the overall survival (OS) and recurrence free survival (RFS) in the meta-analysis were expressed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS Twelve randomized control trials (RCTs) were eligible for final meta-analysis. There was not significant difference in OS between D1 and D2 lymphadenectomy (HR = 0.92, 95% CI: 0.77-1.10, P = 0.36), but subgroup analysis of patients without splenectomy and/or pancreatectomy has a trend for OS much more benefiting D2 compared to D1 patients. A significant RFS improvement was found in favor of D2 lymphadenectomy, sensitivity analysis also gives similar fixed effect estimates (HR = 0.68, 95% CI: 0.58-0.81, P = 0.84). There were no significant differences in OS and RFS between D2 group and D3 group (1 trial). CONCLUSIONS The present meta-analysis indicates that D2 lymphadenectomy with spleen and pancreas preservation offers the most survival benefit for patients with gastric cancer when done safety.
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Affiliation(s)
- Lei Jiang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Feng JF, Huang Y, Liu J, Liu H, Sheng HY, Wei WT, Lu WS, Chen DF, Chen WY, Zhou XM. Risk factors for No. 12p and No. 12b lymph node metastases in advanced gastric cancer in China. Ups J Med Sci 2013; 118:9-15. [PMID: 23039019 PMCID: PMC3572676 DOI: 10.3109/03009734.2012.729103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The risk factors for No. 12p and No. 12b lymph node (LN) metastases in advanced gastric cancer (GC) remain controversial. The aim of this study was to investigate the risk factors for No. 12p and No. 12b LN metastases in advanced GC. METHODS From January 1999 to December 2005, a retrospective analysis of 163 patients with advanced GC who underwent D2 lymphadenectomy in addition to No. 12p and No. 12b LN dissections was conducted. Potential clinicopathological factors that could influence No. 12p and No. 12b LN metastases were statistically analyzed. RESULTS There were 15 cases (9.2%) with No. 12p LN metastases and 5 cases (3.1%) with synchronous No. 12b LN metastases. A logistic regression analysis revealed that the Borrmann type (III/IV versus I/II, P = 0.029), localization (lesser/circular versus greater, P = 0.025), and depth of invasion (pT4 versus pT2/pT3, P = 0.009) were associated with 11.1-, 3.8-, and 5.6-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. A logistic regression analysis also showed that No. 5 (P = 0.006) and No. 12a (P = 0.004) LN metastases were associated with 6.9- and 11.3-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. In addition, significant differences in 5-year survival of patients with and without No. 12p and No. 12b LN metastases were observed (13.3% versus 35.1%, P = 0.022). CONCLUSION We conclude that Borrmann type, localization, and depth of invasion are significant variables for identifying patients with No. 12p and No. 12b LN metastases. Individuals with No. 5 or No. 12a LN metastases should be on high alert for the possibility of additional metastases to the No. 12p and No. 12b LNs.
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Affiliation(s)
- Ji- Feng Feng
- Department of Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Ying Huang
- Nursing Department, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Jing Liu
- Department of General Surgery, Southeast Hospital Affiliated to Xiamen University, Zhangzhou, People's Republic of China
| | - Huang Liu
- Department of Clinical Medicine, Medical College of Xiamen University, Xiamen, People's Republic of China
| | - Hua-Ying Sheng
- Nursing Department, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Wei-Tian Wei
- Department of Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Wei-Shan Lu
- Department of Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Da-Feng Chen
- Department of General Surgery, Southeast Hospital Affiliated to Xiamen University, Zhangzhou, People's Republic of China
| | - Wen-You Chen
- Department of General Surgery, Southeast Hospital Affiliated to Xiamen University, Zhangzhou, People's Republic of China
| | - Xing-Ming Zhou
- Department of Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
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SCHMIDT BENJAMIN, YOON SAMS. D1 versus D2 lymphadenectomy for gastric cancer. J Surg Oncol 2013; 107:259-64. [PMID: 22513454 PMCID: PMC3807123 DOI: 10.1002/jso.23127] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 03/23/2012] [Indexed: 12/14/2022]
Abstract
Significant variability exists throughout the world in the extent of lymphadenectomy that is performed for gastric adenocarcinoma. D2 lymphadenectomy is the standard lymphadenectomy performed in high incidence countries such as Japan and South Korea, and less extensive lymphadenectomies are often performed in lower incidence countries such as the Unites States. This article reviews the evidence on the extent of lymphadenectomy that should be performed for gastric adenocarcinoma.
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Affiliation(s)
- BENJAMIN SCHMIDT
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - SAM S. YOON
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Shigematsu Y, Niwa T, Yamashita S, Taniguchi H, Kushima R, Katai H, Ito S, Tsukamoto T, Ichinose M, Ushijima T. Identification of a DNA methylation marker that detects the presence of lymph node metastases of gastric cancers. Oncol Lett 2012; 4:268-274. [PMID: 22844368 DOI: 10.3892/ol.2012.708] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 05/03/2012] [Indexed: 12/18/2022] Open
Abstract
The accurate detection of the presence of lymph node metastases (LNM) of gastric cancers (GCs) is useful for the implementation of necessary and sufficient treatment, but current methods of detection are unsatisfactory. In the present study, we focused on DNA methylation markers since they have several advantages, including biological and chemical stability and informativeness even in the presence of contaminating cells. Using three metastatic lymph nodes and three primary GCs without LNM, methylation bead array analyses were performed, which enabled the interrogation of 485,577 CpG sites. A total of 31 CpG sites that were hypermethylated in the metastatic lymph nodes, compared with the GCs without LNM, were isolated. Using primary GCs with and without LNM (28 GCs with LNM and 10 without), their methylation levels were measured using quantitative PCR following treatment with sodium bisulfite or a methylation-sensitive restriction enzyme. Of the genomic regions around the 31 CpG sites, 10 regions demonstrated higher methylation levels in the GCs with LNM compared with the GCs without LNM (P<0.05). Finally, the hypermethylation of the 10 regions was validated using another set of samples (129 GCs with LNM and 20 without). Hypermethylation of the region around the cg06436185 CpG site predicted the presence of LNM at a sensitivity of 43% and specificity of 85%. Additionally, the hypermethylation of the region was associated with a poor survival rate among GC patients with LNM. The results of the present study indicated that the methylation status of the region was a promising candidate marker to detect the presence of LNM of GCs and may reflect the malignant potential of GCs.
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Affiliation(s)
- Yasuyuki Shigematsu
- Division of Epigenomics, National Cancer Center Research Institute, Chuo-ku, Tokyo 104-0045
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Mihaljevic AL, Friess H, Schuhmacher C. Clinical trials in gastric cancer and the future. J Surg Oncol 2012; 107:289-97. [PMID: 22514058 DOI: 10.1002/jso.23120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 03/23/2012] [Indexed: 02/06/2023]
Abstract
Following the first successful gastric resection for gastric cancer by Theodor Billroth in 1881 surgery has made tremendous progress leading to improved surgical mortality and morbidity. However, while treatment of early gastric cancer is frequently curative, 5-year survival rates for advanced gastric cancer remain dismal despite the application of perioperative multimodal treatment concepts. In this article we will outline key clinical trials that have lead to an improvement in treatment of gastric cancer patients with specific emphasis on the last 20 years. We will then outline recent concepts and key clinical trials that are currently being conducted in the field. Finally we will outline open questions that remain to be elucidated in the future.
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Affiliation(s)
- André L Mihaljevic
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Abstract
To optimize the therapeutic value of an operation for cancer, surgeons must weigh survival value against mortality/morbidity risk. As a result of several prospective, randomized trials, many surgeons feel that international opinion has reached a consensus. Reflexively radical surgical hubris has certainly given way to a more nuanced, customized approach to this disease. But issues remain. This article critically reviews existing data and emphasizes areas of continued controversy.
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Affiliation(s)
- Scott A Hundahl
- Department of Surgery, U.C. Davis, VA Northern California Health Care System, Sacramento VA at Mather 10535, Hospital Way (112), Mather, CA 95655-1200, USA. ;
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McCulloch P, Nita ME, Kazi H, Gama-Rodrigues JJ. WITHDRAWN: Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach. Cochrane Database Syst Rev 2012; 1:CD001964. [PMID: 22258947 DOI: 10.1002/14651858.cd001964.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer. OBJECTIVES To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer. SEARCH METHODS We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field. For the updated review, the Cochrane Library, M EDLINE , E MBASE and LILACS were searched from 2001 to April 2009. SELECTION CRITERIA Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately. DATA COLLECTION AND ANALYSIS Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons. MAIN RESULTS Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different. AUTHORS' CONCLUSIONS D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.
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Affiliation(s)
- Peter McCulloch
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK
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Schmidt B, Yoon SS. Varying lymphadenectomies for gastric adenocarcinoma in the East compared with the west: effect on outcomes. Am Soc Clin Oncol Educ Book 2012:250-5. [PMID: 24451743 DOI: 10.14694/edbook_am.2012.32.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There are notable differences in surgical approaches to gastric adenocarcinoma throughout the world, particularly in terms of the extent of lymphadenectomy (LAD). In high-incidence countries such as Japan and South Korea, more extensive (e.g., D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity and mortality. In countries such as the United States, where the incidence of gastric adenocarcinoma is 10-fold lower, the majority of patients are treated at nonreferral centers with less extensive (e.g., D1 or D0) lymphadenectomy. There is little disagreement among gastric cancer (GC) experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy, and many of these experts recommend a D2 lymphadenectomy. More extensive lymphadenectomies provide better staging of patient disease and likely reduce locoregional recurrence rates. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity and mortality rates (10% to 13%) in the D2 group. More recent studies have demonstrated that Western surgeons can be trained to perform D2 lymphadenectomies on Western patients with low morbidity and mortality. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. Retrospective analyses and one prospective, randomized trial suggest that there may be a survival benefit to more extensive lymphadenectomies when performed safely, but this assertion requires further validation.
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Affiliation(s)
- Benjamin Schmidt
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Sam S Yoon
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Ding YB, Xia TS, Wu JD, Chen GY, Wang S, Xia JG. Surgical outcomes for gastric cancer of a single institute in southeast China. Am J Surg 2011; 203:217-21. [PMID: 21803328 DOI: 10.1016/j.amjsurg.2010.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 10/31/2010] [Accepted: 10/31/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND In recent years, with social and economic development and lifestyle changes, the incidence of gastric cancer as well as the surgical results and prognoses of patients with gastric cancer have changed significantly in southeast China. METHODS A total of 1,451 patients were divided into 2 groups according to admission time periods. Trends in clinicopathologic characteristics and operative outcomes of these patients were analyzed retrospectively. RESULTS The numbers of old and young patients were significantly increased in period 2 compared with period 1. Tumors located in the proximal stomach increased from 20.26% to 36.83%. The incidence of early gastric cancer was significantly increased from period 1 to period 2. Lymph node metastasis was seen more prevalently in period 2 than in period 1. The rate of operation-related major complications decreased from 5.23% to 1.43%. Operative mortality was .49% in period 1 and .24% in period 2. The 5-year survival rate increased from 38.40% to 53.99%. CONCLUSIONS Early diagnosis, standardized surgical treatment including pertinent lymph node dissection, and better perioperative care notably improve the outcomes of patients with gastric cancer.
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Affiliation(s)
- Yong-Bin Ding
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, China
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50
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Yoo HM, Lee HH, Shim JH, Jeon HM, Park CH, Song KY. Negative impact of leakage on survival of patients undergoing curative resection for advanced gastric cancer. J Surg Oncol 2011; 104:734-40. [PMID: 21792945 DOI: 10.1002/jso.22045] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 07/05/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Leakage has been shown to adversely affect survival in patients undergoing surgery for gastrointestinal malignancies. However, the effect of leakage following radical gastrectomy in patients with gastric cancer remains unclear. METHODS In total, 478 patients with advanced gastric cancer who underwent surgery with curative intent were reviewed. Anastomosis or duodenal stump leakage was diagnosed clinically or radiologically. Risk factors for leakage were evaluated by univariate and multivariate analyses. The impact of leakage on patient survival was analyzed using the Kaplan-Meier method. RESULTS Leakage was diagnosed in 32 of 478 patients (6.7%); 14 patients (2.9%) exhibited esophagojejunal anastomotic leakage, 14 (2.9%) showed duodenal stump leakage, and four (0.8%) showed gastroduodenal anastomotic leakage. Poor performance status [odds ratio (OR): 4.01, 95% confidence interval (CI): 1.80-8.93] and tumor location (OR: 3.74, 95% CI: 1.56-8.89) were risk factors for postoperative leakage. Overall mean survival of patients with leakage was significantly lower than that of patients without leakage (30.5 vs. 96.2 months; P < 0.001). Leakage was one of the independent predictive factor for overall survival [hazard ratio (HR): 3.58, 95% CI: 2.29-5.59]. CONCLUSIONS Postoperative inflammation due to leakage is a negative prognostic factor for patients with advanced gastric cancer.
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Affiliation(s)
- Han Mo Yoo
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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