Ann Surg Oncol DOI 10.1245/s10434-014-3664-z

ORIGINAL ARTICLE – GASTROINTESTINAL ONCOLOGY

Morbidity and Mortality Associated with Gastrectomy for Gastric Cancer Wesley A. Papenfuss, MD, FACS1, Moshim Kukar, MD1, Jacqueline Oxenberg, DO1, Kristopher Attwood, MA, PhD2, Steven Nurkin, MD, MS1, Usha Malhotra, MD3, and Neal W. Wilkinson, MD, FACS1 Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY; 2Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, NY; 3Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 1

ABSTRACT Background. Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning. Material and Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated. Results. Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p \ 0.001; and 5.4 vs. 3.4 %, p \ 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p \ 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p \ 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1;

Ó Society of Surgical Oncology 2014 First Received: 13 December 2013 N. W. Wilkinson, MD, FACS e-mail: [email protected]

p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028). Conclusions. Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.

Gastric cancer remains far from eradicated despite declining global and national trends.1,2 Surgical resection has been the mainstay of treatment for decades and provides the only hope for long-term survival. The optimal extent of surgical resection for gastric cancer has been examined in the literature throughout large clinical series and randomized clinical trials from Eastern and Western countries.3–5 The Eastern experience demonstrates that well-trained and experienced surgeons can perform an appropriate resection and lymphadenectomy for gastric cancer with low morbidity and mortality and where postoperative adjuvant therapy is standard. The Western experience is less optimistic regarding the safety of surgery and the ability to deliver postoperative adjuvant therapy.6,7 Following publication of the Dutch and MRC trial examining D2 lymphadenectomy, many groups have gravitated toward less extensive surgery (D0–1 lymphadenectomy), citing morbidity and mortality concerns outweighing oncologic benefit.8–10 Current national and international guidelines now advocate for safe organ-sparing D2 lymphadenectomy.11–13 Still, limited D0–D1 resections are the most commonly reported lymphadenectomy currently performed.14–16 We see a trend toward less aggressive surgical resection compounded with a decline in experience and training. Our current graduate medical education (GME) in surgery

W. A. Papenfuss et al. TABLE 1 Demographics of patients undergoing gastrectomy for cancer Characteristic

All gastrectomies

Total gastrectomy

Partial gastrectomy

N = 2,580

2,580 (100)

999 (38.7)

1,581 (61.3)

Age (mean ± SD)

66.63 ± 13.61

63.99 ± 13.49

68.30 ± 13.43

Gender 1,507 (58.4)

603 (60.4)

Female

1,072 (41.6)

396 (39.6)

676 (42.8)

2.71 ± 0.60

2.70 ± 0.61

2.72 ± 0.60

General comorbidities Diabetic

\0.001 0.119

Male ASA class (mean ± SD)

p-Valuea

904 (57.2) 0.667

479 (18.7)

161 (16.1)

318 (20.2)

0.005

Weight loss

430 (16.7)

188 (18.8)

242 (15.3)

0.023

Smoker

489 (19.0)

191 (19.1)

298 (18.8)

0.877

Alcohol

90 (3.5)

35 (3.5)

55 (3.5)

1.000

Functionally independent

2,431 (94.2)

951 (95.2)

1,480 (93.6)

0.013

BMI (mean ± SD)

26.50 ± 6.17

26.41 ± 5.99

26.56 ± 6.28

0.645

COPD

144 (5.6)

44 (4.4)

100 (6.3)

0.043

Dyspnea

334 (12.9)

109 (10.9)

225 (14.2)

0.032

1,450 (56.2)

499 (49.9)

951 (60.2)

\0.001

Pulmonary comorbidities

Cardiac comorbidities Hypertension Prior therapy Chemotherapy

123 (4.8)

69 (6.9)

54 (3.4)

\0.001

Radiation

51 (2.0)

34 (3.4)

17 (1.1)

\0.001

Groups did not statistically differ in the rates of other preoperative variables Data are rendered as n (%), unless specified otherwise SD standard deviation, ASA American Society of Anesthesiologists, BMI body mass index, COPD chronic obstructive pulmonary disease a

Comparing the total and partial gastrectomy subgroups

provides inadequate experience in the treatment of gastric cancer. In the GME 2012 general surgery report, current graduates have performed 3.4 partial gastrectomies and 0.9 total gastrectomies over the 5 years in training.17 There is significant debate in the surgical literature concerning morbidity and mortality regarding complex surgical procedures (i.e. pancreatic, esophageal resections).18–20 Not much is written about the need for specialized care in the patient with newly diagnosed gastric cancer as it is about other complex gastrointestinal cancers. The goal of this study is to evaluate the operative morbidity and mortality associated with gastrectomy for malignancy utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS The ACS NSQIP is a multicenter, prospective clinical database created for hospitals for use in risk-adjusted quality

improvement evaluation. Details regarding data collection, variables, and analysis have previously been published.21 The ACS NSQIP Participant Use File was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) at participating NSQIP hospitals from 2005– 2010. Current Procedure Terminology (CPT) codes for total gastrectomy (CPT 43620, 43621, 43622) and partial gastrectomy (CPT 43631, 43632, 43633, 43634) were utilized to identify patient subsets. Prior to 2010, codes for the type of reconstruction (ex. intestinal pouch) were not collected in the NSQIP dataset and therefore the groups were not subdivided. There is no CPT code for proximal gastrectomy. However, proximal gastrectomy was only reported in 3.3 % of gastrectomies in the National Cancer Database dataset and likely would have limited impact upon the findings of this study.16 Emergency cases were excluded from analysis. The ACS NSQIP collects data on more than 130 preoperative, intraoperative, and postoperative variables. Definitions of variables are available elsewhere.22

Morbidity and Mortality for Gastric Cancer TABLE 2 Gastrectomy surgical outcomes: serious morbidity and mortality Characteristic

All gastrectomies (N = 2,580)

Total gastrectomy (N = 999)

Partial gastrectomy (N = 1,581)

Operative time (mean)

225.8 min

268.4 min

198.7 min

Hospital length of stay (mean)

12.3 days

12.99 days

11.64 days

p Valuea \0.001 \0.001

Wound complications (%) Superficial infection

5.6

5.6

5.6

1.0

Deep infection

1.4

1.5

1.4

0.866

Organ space infection

7.0

9.0

5.7

0.001

Dehiscence

1.5

1.8

1.3

0.408

7.1

9.8

5.4

\0.001

Pulmonary complications (%) Pneumonia

5.6

7.6

4.4

\0.001

5.7

7.5

4.6

0.003

Cardiac arrest

1.5

2.0

1.2

0.135

Myocardial infarction

1.2

1.3

1.1

0.707

Pulmonary embolism

1.2

2.0

0.7

0.005

Deep vein thrombosis

1.4

1.6

1.3

0.494

7.0

8.7

5.9

0.009

Failure to wean Reintubation Cardiac complications (%)

Thrombembolic complications (%)

Septic complications (%) Sepsis Septic shock Return to operating room (%) Serious morbidityb (%) 30-day mortality (%)

4.8

7.1

3.4

\0.001

7.6

10.3

5.8

\0.001

23.6

29.3

19.9

\0.001

4.1

5.4

3.4

0.015

a

Comparing the total and partial gastrectomy subgroups

b

Defined in the text

Thirty-day morbidity and mortality were assessed. Serious morbidity was defined as the occurrence of any of the following: superficial and deep organ space infection, dehiscence, re-intubation, prolonged ventilation, pulmonary embolism, acute renal failure requiring dialysis, urinary tract infection, cerebral vascular accident, cardiac arrest, myocardial infarction (MI), need for transfusion greater than 4 units postoperatively, sepsis, septic shock, and return to the operating room. Demographic characteristics were compared between surgery types using the Wilcoxon rank sum and Fisher’s exact tests for continuous and categorical variables, respectively. Outcomes were compared between surgery types using the Wilcoxon rank sum and Fisher’s exact tests for continuous and dichotomous outcomes, respectively. Logistic and linear regression models were performed for assessing multivariate association between patient demographics and the outcome measures of mortality and serious morbidity. A p-value \ 0.05 was chosen for statistical significance. All analyses were performed in SAS version 9.3 (SAS Institute, Cary, NC, USA).

RESULTS The ACS NISQIP registry contained 2,580 patients who underwent gastrectomy for malignancy from January 2005 to December 2010. Selected patient characteristics are listed in Table 1. A total gastrectomy was performed in 999 (38.7 %) patients, and a partial gastrectomy was performed in 1,581 (61.3 %) patients. Operative time (225.8 min), length of stay (12.3 days), and return to the operating room (7.6 %) were calculated for the entire gastrectomy group, as well as subcategorized by surgery type (Table 2). Patients undergoing partial gastrectomy were older (68.3 vs. 64), and more likely to have comorbid conditions, including diabetes (20.2 vs. 16.1 %), decreased functional status (6.4 vs. 4.8 %), chronic obstructive pulmonary disease [COPD] (6.3 vs. 4.4 %), hypertension (HTN) requiring medication (60.2 vs. 49.9 %) and dyspnea (14.2 vs. 10.9 %). Body mass index (BMI) was 26.5 overall and not significantly different between total gastrectomy and partial gastrectomy groups at the time of surgery. However, patients undergoing total gastrectomy were more likely to

W. A. Papenfuss et al. TABLE 3 Univariate and multivariate analysis of factors associated with serious morbidity and mortality

Age Gender ASA classification

Serious morbiditya Univariate

30-day mortality

\0.001

\0.001

0.034

0.229

\0.001

\0.001

0.447

0.011

Outcome

Univariate Multivariate 0.004

Operative time (mean ± SD) Hospital length of stay (mean ± SD)

General comorbidities Ascites

TABLE 4 Gastrectomies comparing additional procedures and outcome

0.002

Gastrectomy with and without major additional procedures Without

Witha

212.4 ± 94.3

262.5 ± 107.3 \0.001

12.01 ± 12.7

p Value

13.23 ± 10.9 \0.001

Wound complications (%)

Esophageal varices

0.631

0.023

Superficial infection

5.2

6.5

History of renal failure

0.147

0.023

Deep infection

1.4

1.5

1.00

Weight loss [ 10 % Disseminated cancer

0.006 0.158

\0.001 0.017

Organ space infection Dehiscence

5.5 1.4

11.0 1.9

\0.001 0.362

Preoperative transfusion

0.400

0.036

\0.001

\0.001

Functionally dependent

0.033

Pulmonary complications (%)

Pulmonary comorbidities History of COPD

0.226

0.048

Dyspnea

0.061

0.003

0.049

0.036

5.8

10.8

\0.001

5.2

6.8

0.122

Reintubation

5.3

6.8

0.152

Cardiac arrest

1.4

1.7

0.585

Myocardial infarction

1.3

0.9

0.534

Thrombembolic complications (%) \0.001

1.000

Prior PCI

0.001

0.019

Hypertension requiring medication

0.224

0.001

History of peripheral vascular disease

0.080

0.011

History of angina

Pneumonia Failure to wean Cardiac complications (%)

Cardiac comorbidities History of myocardial infarction

0.208

0.043

ASA American Society of Anesthesiologists, COPD chronic obstructive pulmonary disease, PCI percutaneous coronary intervention a

Multivariate analysis performed on serious morbidity did not show any significance and is thus not included (see text)

have experienced a 10 % body weight loss in the 6 months prior to surgery (18.8 vs. 15.3 %). Few (4.8 %) patients received chemotherapy prior to surgery (within 30 days) and fewer (1.9 %) received radiation therapy 90 days prior to surgery. Although the numbers are small, more patients in the total gastrectomy group vs. the partial gastrectomy group received preoperative therapy: chemotherapy (6.9 vs. 3.4 %; p \ 0.001) and radiation therapy (3.4 vs. 1.1 %; p \ 0.001), respectively. Due to limited numbers, the contribution of neoadjuvant therapy to morbidity and mortality could not be examined. Serious morbidity occurred in 23.6 % of patients undergoing gastrectomy for cancer. The 30-day mortality was 4.1 %. Table 2 provides a breakdown of morbidity (infectious/septic, pulmonary, cardiac, thromboembolic, return to operating room) and mortality according to the surgery performed; overall, total gastrectomy and partial gastrectomy. Univariate and multivariate analyses were

Pulmonary embolism

1.3

0.9

0.419

Deep vein thrombosis

1.3

1.7

0.348

6.1

9.4

0.005

Septic complications (%) Sepsis Septic shock Return to operating room (%) Serious morbidityb (%) 30-day mortality (%)

3.8

7.7

\0.001

6.4

10.8

\0.001

21.5

29.4

\0.001

3.8

5.1

0.148

a

Abdominal lymphadenectomy, splenectomy, pancreatectomy, colectomy, enterectomy, esophagectomy, hepatectomy

performed to determine factors associated with serious morbidity and 30-day mortality. On univariate analysis, serious morbidity was associated with advanced age, male gender, decreased functional status, history of MI, prior percutaneous coronary intervention (PCI), history of angina, history of dialysis, wound infection, weight loss, American Society of Anesthesiologists (ASA) classification, history of hemiplegia or CVA, and additional procedures. Multivariate analysis failed to identify any further associations. On univariate analyses, 30-day mortality was associated with dyspnea, decreased functional status, COPD, ascites, esophageal varices, prior PCI, HTN, history of peripheral vascular disease, renal insufficiency, disseminated cancer, weight loss, prior transfusion, ASA class, and lower BMI. On multivariate analysis age, ascites, prior PCI, and weight loss were predictors of 30-day mortality (Table 3).

Morbidity and Mortality for Gastric Cancer TABLE 5 Morbidity and mortality based on the need for additional procedures Procedure

Abdominal lymphadenectomy

N (%)

Serious morbidity

[N = 821]

%

Mortality

OR

p Value

%

OR

p Value

431 (16.7)

25.1

1.105 (0.70–1.405)

0.413

2.1

0.468 (0.239–0.920)

0.028

141 (5.5)

38.3

2.119 (1.490–3.014)

\0.001

9.9

2.854 (1.593–5.113)

\0.001

Colectomy

73 (2.8)

41.1

2.237 (1.453–3.759)

\0.001

12.3

3.603 (1.763–7.363)

\0.001

Pancreatectomy

67 (2.6)

49.3

3.271 (2.008–5.3-8)

\0.001

11.9

3.466 (1.635–7.348)

0.001

Enterectomy

52 (2.0)

23.1

1.000 (0.524–1.909)

1.000

9.6

2.741 (1.100–6.829)

0.030

Hepatectomy

31 (1.2)

51.6

3.519 (1.730–7.161)

\0.001

3.2

1.128 (0.211–6.034)

0.888

Esophagectomy

26 (1.0)

38.5

2.081 (0.941–4.602)

0.070

11.5

3.490 (1.092–11.146)

0.035

Splenectomy

OR odds ratio

The inclusion of an additional procedure performed at the time of the index operation was reported in 1,747 of 2,580 gastrectomies (67.7 %). These additional procedures included both major and minor categories based upon physiologic stress and ability to influence the outcome regarding morbidity and mortality. Procedures felt to be unlikely to contribute to morbidity or mortality included 1,073 miscellaneous items, including cholecystectomy, port placement, tube thoracostomy, plus others. A total of 688 patients underwent 821 major additional procedures which were then examined in more detail. The most common additional procedure performed was abdominal lymphadenectomy (16.7 %) followed by splenectomy (5.5 %), colectomy (2.8 %), pancreatectomy (2.6 %) and enterectomy (2.0 %). Lesser frequent major reported procedures included esophagectomy (1.0 %) and hepatectomy (1.2 %). A comparison was performed between patients who underwent additional major procedure (n = 688) versus those who did not (no additional procedure or minor procedure only, n = 1,892). Those patients who had additional procedures had a statistically significant higher incidence of serious morbidity (29.4 vs. 21.5 %; p \ 0.001). Table 4 compares the morbidity associated with and without these additional procedures. Specifically, the rates of organ space infection (11.0 vs. 5.5 %), pneumonia (10.8 vs. 5.8 %), septic shock (7.7 vs. 3.8 %), and return to the operating room (10.8 vs. 6.4 %) were statistically more likely to occur with these additional procedures. There was no difference in mortality between the groups that had additional procedures versus those that did not (5.1 vs. 3.8 %; p = 0.148). Odds ratios (ORs) were calculated for serious morbidity and mortality for additional procedures. There was an associated increase in serious morbidity for the following additional procedures: splenectomy (OR 2.1; p \ 0.001), pancreatectomy (OR 3.3; p \ 0.001), colectomy (OR 2.2; p \ 0.001), and hepatectomy (OR 3.5; p \ 0.001). Serious morbidity was not associated with the following

procedures: abdominal lymphadenectomy (OR 1.1; p = 0.41), enterectomy (OR 1.0; p = 1.0), and esophagectomy (OR 2.1; p = 0.70). There was an associated increase in mortality for the following additional procedures: splenectomy (OR 2.8; p \ 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p \ 0.001), enterectomy (OR 2.7; p = 0.030), and esophagectomy (OR 3.4; p = 0.035). Paradoxically, there was a decrease in mortality associated with abdominal lymphadenectomy (OR 0.468; p = 0.028) (Table 5). DISCUSSION This review of the NSQIP data revealed significant morbidity and mortality associated with gastrectomy for cancer. Total gastrectomy was associated with greater serious morbidity and 30-day mortality than partial gastrectomy even though the total gastrectomy patients were younger with fewer comorbidities. Total gastrectomy in general carried a morbidity and mortality profile that would be prohibitive in a patient with severe comorbidities. In keeping with this trend, we did identify surgical selection favoring lesser surgery, for patients with advanced age and with comorbidities. The need for multivisceral resections was associated with a significant increase in serious morbidity and mortality. The en bloc resection techniques employed (liver, esophagus, pancreas) likely reflected direct tumor extension or T4b disease With an anticipated complication rate of between 20 and 30 %, we could predict a negative impact upon the delivery of adjuvant therapy. This study highlights the conflict between timely delivery of adjuvant therapy and morbidity associated with aggressive surgery. We cannot advocate neoadjuvant therapy based upon the data obtained through NSQIP due to the nature of data collection regarding chemotherapy and radiation therapy. However, this data can provide an anticipated risk of delayed or omitted therapy when aggressive surgery is the initial treatment. Multidisciplinary review of advanced gastric cancer cases and anticipated

W. A. Papenfuss et al.

en bloc resections are necessary for consideration of a perioperative/neoadjuvant approach. Historically, the rational to perform a distal pancreatectomy and splenectomy was to increase the adequacy of the pancreatic and splenic lymphadenectomy. This technique was utilized as a standard procedure when performing a total gastrectomy in the Dutch trial per guidelines at the time.23 Long-term results from the Dutch trial demonstrate a negative effect from pancreaticosplenectomy with regard to morbidity and mortality.24 In the updated Japanese Rules of Gastric Resection 2011, pancreas and spleen preservation techniques are advocated when performing a D2 lymphadenectomy.13 En bloc resection for direct tumor extension into the pancreas is a different clinical situation where en bloc resection would be required to obtain a negative margin resection. In one recent series, en bloc resection combined with extended lymphadenectomy was performed for direct pancreatic involvement. They report 35 % survival for distal pancreatic involvement requiring distal pancreatectomy, and 0 % survival for proximal pancreatic involvement requiring a pancreaticoduodenectomy.25 The oncologic benefits of performing a pancreaticosplenectomy are small with high morbidity, and this approach should be utilized selectively. We examined the morbidity and mortality associated with abdominal lymphadenectomy. NSQIP codes abdominal lymphadenectomy as CPT 38747 (abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes). There was no association between serious morbidity and abdominal lymphadenectomy. However, we identified improved mortality with the addition of abdominal lymphadenectomy, as demonstrated by an OR of 0.468. The impact of extensive surgical lymphadenectomy for gastric cancer is the topic of numerous publications which cite lymph node disease clearance and stage migration as possible explanations for improved outcome.23,26 Within this NSQIP data set, none of the oncologic or staging benefits would be apparent due to limited follow-up of 30 days. Three theoretical justifications exist to explain these results: (1) specialized training in performing D2 lymphadenectomy may enable the surgeon to perform a safer gastrectomy with lymphadenectomy; (2) this may simply reflect patient selection whereby medically unfit patients who are at higher risk of complications are only offered limited ‘safer’ D0 resection; and (3) lymphadenectomy coding may be inaccurate in the NSQIP population with a heterogeneous group of surgeons and variable levels of training. None of these theories can be confirmed with the provided data. Patients with serious complications following surgery are less likely to receive postoperative adjuvant therapy which may negatively impact their overall and disease-

free survival.27,28 In our study, we identified serious morbidity ranging from 19.9 to 29.3 %, and 30-day mortality ranging from 3.4 to 5.4 % depending upon the procedure performed. This means it is likely that up to 35 % of patients experienced a significant delay in the delivery of adjuvant therapy or never received postoperative therapy at all. In the literature, several studies have shown a significant percentage of patients never received adjuvant chemo- or radiation therapy, citing poor tolerance, malnutrition, and postoperative complications.5,29 In the MAGIC trial, 502 patients with T2 or higher gastric, gastroesophageal junction and distal esophageal adenocarcinoma were randomly assigned to surgery versus perioperative chemotherapy and surgery. Although the results favored the perioperative chemotherapy arm with significant improvement in both progression-free survival and overall survival, only 42 % of patients in the perioperative chemotherapy arm were able to complete all therapy. In the perioperative chemotherapy arm, further analysis showed that 91 % of patients were able to complete preoperative therapy, and only 66 % were able to commence postoperative therapy. Thus, the majority of patients failed to receive therapy in the postoperative setting, likely related to various factors related to the operation. Similar results were reported in the French FNLCC/FFCD trial where 48 % of patients failed to receive the planned postoperative therapy.29 There are several limitations to this analysis. The NSQIP does not currently collect cancer-specific variables such as cancer stage, histologic subtype, tumor margins, or resection status (R0–2); it does not assess cancer-specific outcomes (recurrence, survival) but only looks at the 30day outcomes of the surgical event; and does not adequately capture chemotherapy or radiation therapy and thus the data set cannot address many current clinical questions. NSQIP will begin collecting cancer-specific variables in the near future. Individual surgeon volumes or specialty training are not currently accessible in the NSQIP Participant Use File, making volume–outcome comparisons difficult. We believe that there are particular clinical scenarios where more aggressive surgery with its inherent risks provides the optimal long-term cancer outcome. Unfortunately, the NSQIP data cannot measure this impact at this time.

CONCLUSION Gastrectomy for cancer, as performed in NSQIP institutions between 2005 and 2010, continues to carry significant morbidity and mortality. A subset of high-risk patients can be identified based on both patient variables and surgical variables. High-risk patient variables include

Morbidity and Mortality for Gastric Cancer

advanced age, ASA classification, and common general comorbidities. Surgical variables include total gastrectomy and the need for en bloc resection. The addition of abdominal lymphadenectomy does not appear to increase these risks. The combined morbidity and mortality rate of 30 % argues for specialization of care into centers of excellence with high volumes and safe outcomes. Surgeons should seek advanced specialized cancer training if they wish to participate in this high-risk arena. For early-stage gastric cancer, surgical goals should be to perform safe organ-sparing resection with stage-appropriate lymphadenectomy. Any patient who is anticipated to require a total gastrectomy, en bloc resection and postoperative adjuvant therapy should be discussed in an active multidisciplinary setting with clear and honest discussion of surgical morbidity and mortality. Patients with serious medical comorbidities should have appropriate counseling regarding the true risks and benefits of proposed surgery. REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. 2. Bertuccio P, Chatenoud L, Levi F, et al. Recent patterns in gastric cancer: a global overview. Int J Cancer. 2009;125(3):666-673. 3. Hundahl SA, Macdonald JS, Benedetti J, Fitzsimmons T. Surgical treatment variation in a prospective, randomized trial of chemoradiotherapy in gastric cancer: the effect of undertreatment. Ann Surg Oncol. 2002;9(3):278-286. 4. Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001;345(10):725-730. 5. Bonenkamp JJ, Hermans J, Sasako M, Van De Velde CJH. Extended lymph-node dissection for gastric cancer. N Engl J Med. 1999;340(12):908-914. 6. Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer. 1999;79(910):1522-1530. 7. Hundahl SA, Wanebo HJ. Changing gastric cancer treatment in the United States and the pursuit of quality. Eur J Surg Oncol. 2005;31(6):605-615. 8. Hartgritik HH, Van De Velde CJH, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch Gastric Cancer Group trial. J Clin Oncol. 2004;22(11):2069-2077. 9. Ajani JA, Bentrem DJ, Besh S, et al. Gastric cancer, version 2.2013: featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2013;11(5):531-546. 10. Ajani JA, Mayer RJ, Ota DM, et al. Preoperative and postoperative combination chemotherapy for potentially resectable gastric carcinoma. J Natl Cancer Inst. 1993;85(22):1839-1844. 11. Leichman L, Silberman H, Leichman CG, et al. Preoperative systemic chemotherapy followed by adjuvant postoperative intraperitoneal therapy for gastric cancer: a University of Southern California pilot program. J Clin Oncol. 1992;10(12):1933-1942.

12. Wilkinson NW, Howe J, Gay G, Patel-Parekh L, Scott-Conner C, Donohue J. Differences in the pattern of presentation and treatment of proximal and distal gastric cancer: results of the 2001 gastric patient care evaluation. Ann Surg Oncol. 2008;15(6): 1644-1650. 13. Accreditation Council for Graduate Medical Education. General surgery case logs. Updated 2012. http://www.acgme.org/ acgmeweb/Portals/0/GSNatData1112.pdf. 14. La Torre M, Nigri G, Ferrari L, Cosenza G, Ravaioli M, Ramacciato G. Hospital volume, margin status, and long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Am Surg. 2012;78(2):225-229. 15. Kneuertz PJ, Pitt HA, Bilimoria KY, et al. Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg. 2012;16(9):1727-1735. 16. Dhungel B, Diggs BS, Hunter JG, Sheppard BC, Vetto JT, Dolan JP. Patient and peri-operative predictors of morbidity and mortality after esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2008. J Gastrointest Surg. 2010;14(10):1492-1501. 17. Ingraham AM, Richards KE, Hall BL, Ko CY, eds. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251-267. 18. ACS NSQIP. ACS NSQIP – classic. Variables & definitions. Updated 2010. http://nsqip.healthsoftonline.com/lib/Documents/ Ch_4_Variables_Definitions_062810.pdf. Accessed Nov 2013. 19. Sasako M. Gastric cancer eastern experience. Surg Oncol Clin North Am. 2012;21(1):71-77. 20. Songun I, Putter H, Kranenbarg EMK, Sasako M, van de Velde CJH. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide dutch D1D2 trial. Lancet Oncol. 2010;11(5):439-449. 21. Sano T, Kodera Y. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011;14(2):113-123. 22. Min JS, Jin SH, Park S, Kim SB, Bang HY, Lee JI. Prognosis of curatively resected pT4b gastric cancer with respect to invaded organ type. Ann Surg Oncol. 2012;19(2):494-501. 23. Hundahl SA. Surgery for gastric cancer: what the trials indicate. Surg Oncol Clin North Am. 2012;21(1):79-97. 24. Van der Geest LGM, Portielje JEA, Wouters MWJM, et al. Complicated postoperative recovery increases omission, delay and discontinuation of adjuvant chemotherapy in patients with stage III colon cancer. Colorectal Dis. 2013;15(10):E582-E591. 25. Merkow RP, Bentrem DJ, Mulcahy MF, et al. Effect of postoperative complications on adjuvant chemotherapy use for stage III colon cancer. Ann Surg. 2013;258(6):847-853. 26. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20. 27. Bouche´ O, Ychou M, Burtin P, et al. Adjuvant chemotherapy with 5-fluorouracil and cisplatin compared with surgery alone for gastric cancer: 7-year results of the FFCD randomized phase III trial (8801). Ann Oncol. 2005;16(9):1488-1497. 28. Merkow RP, Kmiecik TE, Bentrem DJ, et al. Effect of including cancer-specific variables on models examining short-term outcomes. Cancer. 2013;119(7):1412-1419. 29. Ychou M, Boige V, Pignon JP, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol. 2011;29(13):1715–1721.

Morbidity and mortality associated with gastrectomy for gastric cancer.

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complicati...
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