1
|
Dejeu V, Dejeu P, Muresan A, Bradea P, Dejeu D. Analysis of Patient Outcomes following Curative R0 Multiorgan Resections for Locally Advanced Gastric Cancer: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3010. [PMID: 38792552 PMCID: PMC11121797 DOI: 10.3390/jcm13103010] [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: 03/31/2024] [Revised: 04/30/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Background: This systematic review examines the efficacy of multiorgan resection (MOR) in treating locally advanced gastric cancer (LAGC), focusing on survival outcomes, postoperative morbidity, and mortality. Methods: We conducted a comprehensive search of studies in PubMed, Scopus, and Embase up to November 2023, based on the PRISMA guidelines. The inclusion criteria focused on clinical trials, observational studies, case-control studies, and qualitative research, involving patients of any age and gender diagnosed with LAGC undergoing MOR aimed at R0 resection, with secondary outcomes focusing on survival rates, postoperative outcomes, and the effects of adjuvant and neoadjuvant therapies. Exclusion criteria ruled out non-human studies, research not specifically focused on LAGC patients undergoing MOR, and studies lacking clear, quantifiable outcomes. The quality assessment was performed using the Newcastle-Ottawa Scale. The final analysis included twenty studies, involving a total of 2489 patients across a time span from 2001 to 2023. Results highlighted a significant variation in median survival times ranging from 10 to 27 months and R0 resection rates from 32.1% to 94.3%. Survival rates one-year post-R0 resection varied between 46.7% and 84.8%, with an adjusted weighted mean of 66.95%. Key predictors of reduced survival included esophageal invasion and peritoneal dissemination, the presence of more than six lymph nodes, and tumor sizes over 10 cm. Nevertheless, the meta-analysis revealed a significant heterogeneity (I2 = 87%), indicating substantial variability across studies, that might be caused by differences in surgical techniques, patient demographics, and treatment settings which influence survival outcomes. Results: The review underlines the important role of achieving R0 resection status in improving survival outcomes, despite the high risks associated with MOR. Variability across studies suggests that local practice patterns and patient demographics significantly influence results. Conclusions: The findings emphasize the need for aggressive surgical strategies to improve survival in LAGC treatment, highlighting the importance of achieving curative resection despite inherent challenges.
Collapse
Affiliation(s)
- Viorel Dejeu
- Bariatric Surgery Department, Life Memorial Hospital, Calea Grivitei 365, 010719 Bucuresti, Romania;
| | - Paula Dejeu
- Laboratory Medicine Unit, Betania Medical Center, Menumorut 12, 410004 Oradea, Romania
| | - Anita Muresan
- Surgical Oncology Department, Emergency County Hospital Oradea, Strada Gheorghe Doja 65, 410169 Oradea, Romania; (A.M.); (D.D.)
| | - Paula Bradea
- Gastroenterology Unit, Betania Medical Center, Menumorut 12, 410004 Oradea, Romania;
| | - Danut Dejeu
- Surgical Oncology Department, Emergency County Hospital Oradea, Strada Gheorghe Doja 65, 410169 Oradea, Romania; (A.M.); (D.D.)
- Bariatric Surgery Department, Medlife Humanitas Hospital, Strada Frunzisului 75, 400664 Cluj Napoca, Romania
| |
Collapse
|
2
|
Nakamura N, Kinami S, Kaida D, Tomita Y, Miyata T, Miyashita T, Fujita H, Ueda N, Takamura H. Prognostic factors in T4b gastric cancer after surgery: A more balanced and sequential therapy for patients? J Cancer Res Ther 2024; 20:211-215. [PMID: 38554323 DOI: 10.4103/jcrt.jcrt_811_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/16/2022] [Indexed: 04/01/2024]
Abstract
INTRODUCTION This study aimed to evaluate the prognostic factors in T4b gastric cancer (GC) in order to improve future therapeutic strategies. METHODS We retrospectively analyzed the medical records of 43 patients with advanced GC who underwent surgery and were surgically or pathologically diagnosed with T4b GC. The overall survival (OS) rate of patients with T4b GC was analyzed, and univariate and multivariate analyses were performed to identify clinicopathological factors that were independently associated with OS. In addition, we assessed the relationship between postoperative chemotherapy and laboratory parameters 4 weeks post-surgery. RESULTS The proportion of patients with invasion of cancer in organs, including the pancreas, transverse colon, and liver, were 58.1%, 18.6%, and 14.0%, respectively. The proportion of patients who exhibited distant metastases was 44.2%, and R0 resection was achieved in 30.2% of patients. A total of 69.8% of patients underwent postoperative chemotherapy. The median survival rate was 12.3 months. Upon multivariate analysis, the presence of distant metastases (P = 0.01, HR; 3.48), the use of postoperative chemotherapy (P = 0.0004, HR; 0.12), and R0 resection (P < 0.0001, HR; 0.14) were significantly correlated with OS. Patients who did not undergo postoperative chemotherapy showed significantly higher levels of inflammatory parameters and lower levels of nutritional parameters 4 weeks after surgery than those who did. CONCLUSIONS We evaluated that the presence of distant metastases was significantly associated with a poor prognosis, and the use of postoperative chemotherapy and R0 resection was significantly associated with a better prognosis in patients with T4b GC. It would be more important for a T4b GC treatment to balance between therapeutic tolerance for postoperative chemotherapy and surgical therapeutic effect.
Collapse
Affiliation(s)
- Naohiko Nakamura
- Department of Surgical Oncology, Kanazawa Medical University Hospital, Kahoku, Ishikawa, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Bobrzyński Ł, Pach R, Szczepanik A, Kołodziejczyk P, Richter P, Sierzega M. What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer? Langenbecks Arch Surg 2023; 408:442. [PMID: 37987850 PMCID: PMC10663187 DOI: 10.1007/s00423-023-03187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Locally advanced gastric cancer (GC) extending to the surrounding tissues may require a multivisceral resection (MVR) to provide the best chance of cure. However, little is known about how the extent of organ resection affects the risks and benefits of surgery. METHODS An electronic database of patients treated between 1996 and 2020 in an academic surgical centre was reviewed. MVRs were defined as partial or total gastrectomy combined with splenectomy, distal pancreatectomy, or partial colectomy. RESULTS Suspected intraoperative tumour invasion of perigastric organs (cT4b) was found in 298 of 1476 patients with non-metastatic GC, and 218 were subject to MVRs, including the spleen (n = 126), pancreas (n = 51), and colon (n = 41). MVRs were associated with higher proportions of surgical and general complications, but not mortality. A nomogram was developed to predict the risk of major postoperative morbidity (Clavien-Dindo's grade ≥ 3a), and the highest odds ratio for major morbidity identified by logistic regression modelling was found for distal pancreatectomy (2.53, 95% CI 1.23-5.19, P = 0.012) and colectomy (2.29, 95% CI 1.04-5.09, P = 0.035). Margin-positive resections were identified by the Cox proportional hazards model as the most important risk factor for patients' survival (hazard ratio 1.47, 95% CI 1.10-1.97). The extent of organ resection did not affect prognosis, but a MVR was the only factor reducing the risk of margin positivity (OR 0.44, 95% CI 0.21-0.87). CONCLUSIONS The risk of multivisceral resections is associated with the organ being removed, but only MVRs increase the odds of complete tumour clearance for locally advanced gastric cancer.
Collapse
Affiliation(s)
- Łukasz Bobrzyński
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Radosław Pach
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Antoni Szczepanik
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Piotr Kołodziejczyk
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Piotr Richter
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland
| | - Marek Sierzega
- First Department of Surgery, Jagiellonian University Medical College, 2 Jakubowski Street, 30-688, Cracow, Poland.
| |
Collapse
|
4
|
Vladov N, Trichkov T, Mihaylov V, Takorov I, Kostadinov R, Lukanova T. Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review? Surg J (N Y) 2023; 9:e28-e35. [PMID: 36742159 PMCID: PMC9897905 DOI: 10.1055/s-0043-1761278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/05/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.
Collapse
Affiliation(s)
- Nikola Vladov
- Department of HPB Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
| | - Tsvetan Trichkov
- Department of HPB Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria,Address for correspondence Tsvetan Trichkov, MD Department of HPB Surgery and TransplantologyMilitary Medical Academy, Sveti Georgi Sofiyski str. No.3, floor 14, SofiaBulgaria
| | - Vassil Mihaylov
- Department of HPB Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
| | - Ivelin Takorov
- First Department of Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria
| | - Radoslav Kostadinov
- Department of HPB Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
| | - Tsonka Lukanova
- First Department of Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria
| |
Collapse
|
5
|
Zhang X, Wang W, Zhao L, Niu P, Guo C, Zhao D, Chen Y. Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center. J Cancer 2022; 13:3113-3120. [PMID: 36046640 PMCID: PMC9414031 DOI: 10.7150/jca.75456] [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: 05/24/2022] [Accepted: 07/12/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Multivisceral resection is occasionally necessary for pT4b gastric cancer patients to achieve negative margin. The purpose of this study is to assess the short-term safety and long-term efficacy of this approach. Methods: A single-center, retrospective analysis was conducted for pT4b gastric cancer patients after curative-intent multivisceral resection from the China National Cancer Center Gastric Cancer Database (NCCGCDB) from 1998 to 2018. The postoperative complications, recurrence patterns, long-term survival, and prognostic factors were analyzed. Results: A total of 210 patients were included in the study. The most common combined resection organs were multiple organs (30.5%), pancreas (20.5%), colon (16.7%), and liver (9.0%). Seventeen patients (8.1%) developed postoperative complications and hospital death was observed in one patient (0.5%). The most common postoperative complications were anastomotic leak (4.3%) and intra-abdominal infection (5.7%). The 3-year and 5-year disease-free survival (DFS) rates for the patients investigated were 38.0% and 33.8%, respectively, and the 3-year and 5-year overall survival (OS) rates were 48.2% and 39.1%, respectively. Multivariate Cox regression analysis proved that negative nerve invasion was independent risk factors for DFS (HR: 2.202, 95%CI: 1.144-4.236, P=0.018) and OS (HR: 2.219, 95%CI: 1.164-4.231, P=0.015). Conclusions: Multivisceral resection in pT4b gastric cancer patients without distant metastasis was effective and had an acceptable safety profile.
Collapse
Affiliation(s)
- Xiaojie Zhang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wanqing Wang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Lulu Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Penghui Niu
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chunguang Guo
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dongbing Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yingtai Chen
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
6
|
Nakamura N, Kinami S, Fujita J, Kaida D, Tomita Y, Miyata T, Fujita H, Ueda N, Takamura H. Advanced gastric cancer with abdominal wall invasion treated with curative resection after chemotherapy: a case report. J Med Case Rep 2021; 15:230. [PMID: 33964982 PMCID: PMC8106858 DOI: 10.1186/s13256-021-02820-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In patients with gastric cancer, 6-27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients. CASE PRESENTATION A 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer (L-Circ type 3 T4b N2 M0 H0 stage IVA, based on the 15th edition of the Japanese Classification of Gastric Carcinoma) with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/m2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively. CONCLUSIONS We report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer.
Collapse
Affiliation(s)
- Naohiko Nakamura
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan.
| | - Shinichi Kinami
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Jun Fujita
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Daisuke Kaida
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Yasuto Tomita
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Takashi Miyata
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hideto Fujita
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Nobuhiko Ueda
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hiroyuki Takamura
- Department of Surgical Oncology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| |
Collapse
|
7
|
Aversa JG, Diggs LP, Hagerty BL, Dominguez DA, Ituarte PHG, Hernandez JM, Davis JL, Blakely AM. Multivisceral Resection for Locally Advanced Gastric Cancer. J Gastrointest Surg 2021; 25:609-622. [PMID: 32705611 PMCID: PMC9274296 DOI: 10.1007/s11605-020-04719-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Locally advanced gastric cancer (LAGC) presents a therapeutic dilemma, particularly as it often involves adjacent organs through desmoplasia or true pathologic invasion. To obtain a margin-negative resection, these tumors require en bloc gastrectomy with multivisceral resection (G+MVR), and contention remains regarding its safety and oncologic benefit. METHODS We used the National Cancer Database to retrospectively evaluate the short- and long-term outcomes of patients with LAGC treated in the USA between 2004 and 2016. Associations with margin status and perioperative outcomes were calculated using logistic regression. Survival was estimated using Cox proportional hazards regression and the Kaplan-Meier method. RESULTS Overall, 785 pathologic stage T4b (pT4b) patients diagnosed with LAGC underwent gastrectomy (n = 438) or G+MVR (n = 347). There was no association between G+MVR and short- or long-term mortality. Positive resection margins (HR 1.68, 95% CI 1.40-2.03), the presence of nodal disease (HRs 1.46-1.50), treatment at a high-volume center (HR 0.76, 95% CI 0.68-0.85), and the receipt of adjuvant chemotherapy (HR 0.64, 95% CI 0.51-0.80) were independently associated with overall survival. Diffuse-type histology was associated with higher rates of an R1 resection (OR 3.60, 95% CI 2.20-5.87). Perioperative and long-term survival metrics were comparable between patients with pT4a and pT4b LAGC who underwent a margin-negative G+MVR. Undergoing a margin-negative G+MVR imparted a 6-month survival benefit over non-curative gastrectomy alone (p < 0.001). CONCLUSIONS Our study demonstrates the safety and long-term feasibility of G+MVR for disease clearance in well-selected patients with LAGC, and we advocate for their referral to high-volume centers for optimal care.
Collapse
Affiliation(s)
- John G Aversa
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Laurence P Diggs
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brendan L Hagerty
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dana A Dominguez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jeremy L Davis
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew M Blakely
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
8
|
Yang Y, Hu J, Ma Y, Chen G, Liu Y. Multivisceral resection for locally advanced gastric cancer: A retrospective study. Am J Surg 2020; 221:1011-1017. [PMID: 33036727 DOI: 10.1016/j.amjsurg.2020.09.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Multivisceral resection may be the exclusive radical procedure for cT4b gastric cancer patients. However, most surgeons refuse to select surgery because of the theoretical higher mortality, morbidity and poorer prognosis. METHODS We retrospectively reviewed cT4b gastric cancer patients who underwent surgery from January 1,1997 to December 31,2018. The primary endpoint was overall survival. Short-term results and prognostic values of clinical and pathologic factors were also analyzed. RESULTS Patients underwent multivisceral resection had an acceptable mortality and morbidity. The overall 5-year survival rate of multivisceral resection was higher than that of palliative surgery (P < 0.05). And independent prognostic factors of multivisceral resection were R+ resection, extensive lymph node involved (>15), vascular cancer emboli, and postoperative chemotherapy. CONCLUSIONS cT4b gastric cancer patients underwent multivisceral resection experience acceptable mortality and morbidity. The independent prognostic factors for multivisceral resection were completeness of resection, extensive lymph node involvement (>15), vascular cancer emboli, and postoperative chemotherapy.
Collapse
Affiliation(s)
- Yanpeng Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jianwen Hu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yongchen Ma
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Guowei Chen
- Department of General Surgery, Peking University First Hospital, Beijing, China.
| | - Yucun Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China.
| |
Collapse
|
9
|
Wang GC, Liu YJ, Gao CQ, Wang YC, Lv HF, Chen BB, Nie CY, Chen XB, Luo SX. Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:947. [PMID: 32953747 PMCID: PMC7475396 DOI: 10.21037/atm-20-3377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background For the treatment of locally advanced (T4) gastric cancer, extended multi-organ resection remains controversial. This study aimed to evaluate the surgical outcomes and survival of patients with T4 gastric cancer extending to the transverse colon. Methods A total of 2,652 gastric cancer patients underwent surgery between December 2011 and December 2015. Data from 40 of these patients who underwent curative resection for T4 gastric cancer extending to the transverse colon were obtained. Patient characteristics, related complications, long-term survival, and prognostic factors for T4 gastric cancer were analyzed. Results Postoperative morbidity occurred in 5 (12.5%) patients. All of the patients were cured with conservative treatment. No procedure-related mortality occurred. The 1-, 3-, and 5-year overall survival (OS) rates were 75.0%, 49.2%, and 36.9%, respectively, with a median survival time of 24 months. Univariate analysis revealed tumor size (P=0.049), advanced T stage (P=0.013), and lymph node metastasis (P=0.006) to be poor prognostic factors of OS. Advanced T stage and lymph node metastasis were identified by multivariate analysis as being independent prognostic factors. Further, it was observed that lymph node metastasis grade was associated with poorer OS. Conclusions Patients with T4 gastric cancer extending to the transverse colon might benefit from curative resection with acceptable morbidity and mortality.
Collapse
Affiliation(s)
- Gang-Cheng Wang
- Department of General Surgery, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Ying-Jun Liu
- Department of General Surgery, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Chong-Qing Gao
- Department of General Surgery, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - You-Cai Wang
- Department of General Surgery, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Hui-Fang Lv
- Department of Gastrointestinal Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Bei-Bei Chen
- Department of Gastrointestinal Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Cai-Yun Nie
- Department of Gastrointestinal Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Xiao-Bing Chen
- Department of Gastrointestinal Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Su-Xia Luo
- Department of Gastrointestinal Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| |
Collapse
|
10
|
Dias AR, Pereira MA, Ramos MFKP, Oliveira RJ, Ribeiro U, Zilberstein B, Cecconello I. Prediction scores for complication and recurrence after multivisceral resection in gastric cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:1097-1102. [PMID: 31987704 DOI: 10.1016/j.ejso.2020.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/29/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Multivisceral resection (MVR) is indicated in T4b gastric cancer (GC) when R0 can be achieved. Patient's selection for MVR is imperative, since it carries an increased risk for postoperative complications (POC) and disease recurrence. This study aims to elaborate prediction scores for POC and recurrence after MVR for cT4b GC. METHODS Patients who underwent MVR with curative intent due to cT4b gastric adenocarcinoma were selected from our prospective database. Scoring models were based on the variables identified as risk factors for the studied outcome. Through binary regression the model that best predicted the outcome was created. RESULTS From 237 MVRs, 58 fulfilled the inclusion criteria. Males were 70.7%, mean age was 61.8 years. A pT4b was confirmed in 34 patients, 29 had 2 or more adjacent organs removed. Major POC occurred in 25.9%, mortality was 8.6%. Overall survival (OS) and disease-free survival (DFS) were similar for pT4b and non-pT4b. DFS was worse for pN+ and when >2 adjacent organs were removed. Scoring models included 5 and 6 parameters for POC and recurrence, respectively, and their accuracy was 80.6% (95%CI = 0.69-0.92) and 78% (95%CI = 0.66-0.90). The POC and recurrence rates in low- and high-score groups were statistically different (p < 0.001 and p = 0.004, respectively). Patients with high-risk for POC had lower OS (p = 0.036) and DFS was worse in the high-recurrence risk group (p = 0.008). CONCLUSION The proposed scoring systems accurately predict POC and recurrence in GC patients undergoing MVR. These models are easy to use and can assist in the adoption of an individualized approach.
Collapse
Affiliation(s)
- Andre Roncon Dias
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil.
| | - Marina Alessandra Pereira
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | | | - Rodrigo Jose Oliveira
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Bruno Zilberstein
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Ivan Cecconello
- Cancer institute, Hospital das Clinicas, University of São Paulo School of Medicine, Sao Paulo, Brazil
| |
Collapse
|
11
|
Dias AR, Pereira MA, Oliveira RJ, Ramos MFKP, Szor DJ, Ribeiro U, Zilberstein B, Cecconello I. Multivisceral resection vs standard gastrectomy for gastric adenocarcinoma. J Surg Oncol 2020; 121:840-847. [PMID: 32003476 DOI: 10.1002/jso.25862] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/17/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Multivisceral resection (MVR) is potentially curative for selected gastric cancer patients, supposedly at the cost of increased complications. However, current data comparing MVR to standard gastrectomy (SG) is lacking. OBJECTIVES Compare complications and survival after MVR and SG. METHODS In a retrospective cohort of 1015 patients with gastric adenocarcinoma, 58 underwent MVR and 466 SG. Groups were compared concerning their characteristics, complications, and survival. RESULTS One hundred seventy-six patients had postoperative complications. Major complications were more frequent after MVR (P = .002). Surgical mortality was 8.6% and 4.9% for MVR and SG (P = .221). Older age, higher morbidities, and MVR were independent risk factors for major complications. The odds ratio for major complications was 5.89 for MVR with one or two organs and 38.01 for MVR with three or more organs. The pancreas was the most commonly removed organ and pT4b disease were confirmed in 34 (58.6%) of the MVR cases. Disease-free survival (DFS) was lower in MVR patients (51% vs 77.8%; P < .001), being worse according to the number of organs resected. In pN+ patients, DFS was worse after MVR. DFS was equivalent to pT4b and non-pT4b in the MVR group. CONCLUSIONS Increased morbidity and lower survival are expected for gastric cancer patients undergoing MVR.
Collapse
Affiliation(s)
- Andre R Dias
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Marina A Pereira
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Rodrigo J Oliveira
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Marcus F K P Ramos
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel J Szor
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Bruno Zilberstein
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ivan Cecconello
- Gastrointestinal Surgery Division, Department of Gastroenterology, Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| |
Collapse
|
12
|
Nadiradze G, Yurttas C, Königsrainer A, Horvath P. Significance of multivisceral resections in oncologic surgery: A systematic review of the literature. World J Meta-Anal 2019; 7:269-289. [DOI: 10.13105/wjma.v7.i6.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.
AIM To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.
METHODS PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.
RESULTS Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.
Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.
CONCLUSION MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.
Collapse
Affiliation(s)
- Giorgi Nadiradze
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Can Yurttas
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
- National Center for Pleura and Peritoneum, Tübingen 72076, Germany
| |
Collapse
|
13
|
Chen Y, Zhang G, Zhao B, Huang C, Ling Y, Li Y, Zhou Z. A better prognostic stratification for the 8th edition of the AJCC staging system of gastric cancer by incorporating pT4aN0M0 into stage IIIA. Surg Oncol 2019; 29:90-96. [PMID: 31196500 DOI: 10.1016/j.suronc.2019.03.005] [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: 07/22/2018] [Revised: 03/12/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The aim of this study was to analyze the prognosis of gastric cancer patients categorized as pT4aN0M0, pT1N3aM0/pT2N2M0/pT3N1M0 of stage IIB and stage IIIA and to compare the optimistic prognostic stratification between the AJCC 8th edition staging system and the AJCC modified 8th (m8th) edition staging system by incorporating pT4aN0M0 into stage IIIA. MATERIAL AND METHODS A total of 1770 patients who underwent gastrectomy were enrolled in this study. The homogeneity, the discriminatory ability, the monotonicity of the gradient assessments, and the discriminatory ability of the AJCC 8th and m8th edition staging systems were compared by using the likelihood ratio χ2 test, a linear trend χ2 test, the Akaike information criteria (AIC) and Bayesian information criterion (BIC) calculations, respectively. RESULTS For patients staged IIB, the 5-year survival rate of the patients categorized as pT4aN0M0 were significantly worse than that of the patients categorized as pT1N3aM0/pT2N2M0/pT3N1M0 (59.9% vs. 72.4%, P = 0.036). By contrast, the prognoses of the patients between the pT4aN0M0 category and those staged IIIA were analogous (59.9% vs. 61.5%, P = 0.693). Compared with the 8th edition system, the modified 8th edition staging system had a better homogeneity (higher likelihood ratio χ [2] score, 441.17 vs. 436.24), discriminatory ability, monotonicity of gradients (higher linear trend χ2 score, 436.78 vs. 416.15) and smaller AIC (10364.98 vs. 10369.91) and BIC values (10447.13 vs. 10452.06). CONCLUSIONS The prognosis of pT4aN0M0 was poorer than those of pT1N3aM0, pT2N2M0, and pT3N1M0, which were staged IIB. There is a better prognostic stratification for the AJCC 8th edition staging system of gastric cancer by incorporating pT4aN0M0 into stage IIIA.
Collapse
Affiliation(s)
- Yongming Chen
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guanrong Zhang
- Information and Statistics Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Baiwei Zhao
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chunyu Huang
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yihong Ling
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yuanfang Li
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.
| | - Zhiwei Zhou
- State Key Laboratory of Oncology in South China, Guangzhou, China; Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.
| |
Collapse
|
14
|
van der Werf LR, Eshuis WJ, Draaisma WA, van Etten B, Gisbertz SS, van der Harst E, Liem MSL, Lemmens VEPP, Wijnhoven BPL, Besselink MG, van Berge Henegouwen MI. Nationwide Outcome of Gastrectomy with En-Bloc Partial Pancreatectomy for Gastric Cancer. J Gastrointest Surg 2019; 23:2327-2337. [PMID: 30820797 PMCID: PMC6877485 DOI: 10.1007/s11605-019-04133-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim of this study was to evaluate the outcome of gastrectomies with partial pancreatectomy for gastric cancer. METHODS Patients who underwent gastrectomy with or without partial pancreatectomy for gastric or gastro-oesophageal junction cancer between 2011 and 2015 were selected from the Dutch Upper GI Cancer Audit (DUCA). Outcomes were resection margin (pR0) and Clavien-Dindo grade ≥ III postoperative complications and survival. The association between partial pancreatectomy and postoperative complications was analyzed with multivariable logistic regression. Overall survival of patients with partial pancreatectomy was estimated using the Kaplan-Meier method. RESULTS Of 1966 patients that underwent gastrectomy, 55 patients (2.8%) underwent en-bloc partial pancreatectomy. A pR0 resection was achieved in 45 of 55 patients (82% versus 85% in the group without additional resection, P = 0.82). Clavien-Dindo grade ≥ III complications occurred in 21 of 55 patients (38% versus 17%, P < 0.001). Median overall survival [95% confidence interval] was 15 [6.8-23.2] months. For patients with and without perioperative systemic therapy, median survival was 20 [12.3-27.7] and 10 [5.7-14.3] months, and for patients with pR0 and pR1 resection, it was 20 [11.8-28.3] and 5 [2.4-7.6] months, respectively. CONCLUSIONS Gastrectomy with partial pancreatectomy is not only associated with a pR0 resection rate of 82% but also with increased postoperative morbidity. It should only be performed if a pR0 resection is feasible.
Collapse
Affiliation(s)
- L. R. van der Werf
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - W. J. Eshuis
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - W. A. Draaisma
- grid.414725.10000 0004 0368 8146Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
| | - B. van Etten
- grid.4494.d0000 0000 9558 4598Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - S. S. Gisbertz
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - E. van der Harst
- grid.416213.30000 0004 0460 0556Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - M. S. L. Liem
- grid.415214.70000 0004 0399 8347Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - V. E. P. P. Lemmens
- grid.5645.2000000040459992XDepartment of Pubic Health, Erasmus University Medical Centre, Rotterdam, the Netherlands ,Department of Research, Comprehensive Cancer Organisation the Netherlands, Utrecht, the Netherlands
| | - B. P. L. Wijnhoven
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - M. I. van Berge Henegouwen
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | | |
Collapse
|
15
|
Molina JC, Al-Hinai A, Gosseling-Tardif A, Bouchard P, Spicer J, Mulder D, Mueller CL, Ferri LE. Multivisceral Resection for Locally Advanced Gastric and Gastroesophageal Junction Cancers-11-Year Experience at a High-Volume North American Center. J Gastrointest Surg 2019; 23:43-50. [PMID: 29663302 DOI: 10.1007/s11605-018-3746-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 03/13/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The oncologic benefit of multivisceral en bloc resections for T4 gastroesophageal tumors has been questioned, given the increased morbidity associated. We thus sought to investigate the surgical and oncologic outcomes of curative-intent en bloc multivisceral resections for T4 gastroesophageal carcinomas. METHODS Between 2005 and 2016, 35 of the 525 patients who had gastric or EGJ carcinomas underwent curative-intent multivisceral resections for direct invasion or adhesion to adjacent organs. RESULTS Postoperative complications occurred in 16(46%), 10 of which were Clavien-Dindo ≥ 3 (29%). Ninety-day mortality was 3%. The R0 resection rate was 94% (33). Direct organ invasion (pT4b) was confirmed on pathological analysis in 14 (40%) and did not affect survival. The majority (28, 80%) had lymph node involvement with a high nodal disease burden and was associated with decreased survival. Overall 5-year survival rate was 34%, and the vast majority of recurrences were distant/peritoneal (81%). On multivariate analysis, positive lymph nodes (H.R. 21.2; 95%CI 2.34-192) and R1 resection (H.R. 5.6; 95%CI 1.02-30.9) were predictors of survival. CONCLUSION Multivisceral resections for T4 gastric and GEJ adenocarcinomas, in combination with effective systemic therapy, result in prolonged long-term survival with acceptable morbidity. Complete resection to negative margins should remain a mainstay of curative-intent treatment in carefully selected patients.
Collapse
Affiliation(s)
- J C Molina
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada.
| | - A Al-Hinai
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - A Gosseling-Tardif
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - P Bouchard
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - J Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D Mulder
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - C L Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - L E Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
16
|
Abstract
BACKGROUND Multivisceral resections seem to be naturally associated with an elevated morbidity rate. Data regarding the impact of multivisceral resections on progression-free and overall survival are only available in insufficient quantities. OBJECTIVE Data on multivisceral resections in cancer surgery are presented exemplified by gastric cancer, colorectal cancer and peritoneal metastases, focusing on overall and progression-free survival as well as morbidity and mortality. MATERIAL AND METHODS A PubMed search was carried out including the following terms: multivisceral resection, peritoneal metastases, cytoreduction, morbidity, HIPEC (hyperthermic intraperitoneal chemotherapy) RESULTS: Multivisceral resections should only be performed if an R0 status can be achieved for all tumor entities. Preoperative performance of an FDG-PET-CT scan (fluorodeoxyglucose positron emission tomography computed tomography scan) can help in the selection of appropriate patients. In gastric cancer, extensive lymphatic metastases are associated with a poor overall survival despite multivisceral resection. Recurrent rectal cancer shows elevated morbidity rates and also decreased overall survival rates. Maximum cytoreductive surgery can be conducted for peritoneal metastasized appendiceal neoplasms and colorectal cancer with acceptable morbidity and without an increased risk for reduced overall survival. CONCLUSION After adequate patient selection and exclusion of stage IV distant metastatic disease, multivisceral resections can be offered to patients with the goal of an R0 resection.
Collapse
Affiliation(s)
- P Horvath
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - A Königsrainer
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
| |
Collapse
|
17
|
DA Silva AM. Multiorganic resections in gastric cancer. ACTA ACUST UNITED AC 2017; 44:549-552. [PMID: 29267550 DOI: 10.1590/0100-69912017006012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- André Maciel DA Silva
- - Head, General Surgery Service, Federal Hospital of Andaraí MS/RJ; Oncologic Surgeon, Service of Abdominal-Pelvic Surgery, National Cancer Institute, Rio de Janeiro, RJ, Brazil
| |
Collapse
|
18
|
Mita K, Ito H, Katsube T, Tsuboi A, Yamazaki N, Asakawa H, Hayashi T, Fujino K. Prognostic Factors Affecting Survival After Multivisceral Resection in Patients with Clinical T4b Gastric Cancer. J Gastrointest Surg 2017; 21:1993-1999. [PMID: 28940122 DOI: 10.1007/s11605-017-3559-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/21/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prognosis and survival of patients with advanced gastric cancer is poor. Although completeness of resection (R0) is one of the most important factors affecting survival, multivisceral resection (MVR) for locally advanced (clinical T4b, cT4b) gastric cancer remains controversial. The aim of this study was to evaluate the factors affecting prognosis and survival after MVR in patients with cT4b gastric cancer. METHODS Between 2005 and 2015, we retrospectively reviewed the medical records of 103 patients who underwent MVR for cT4b gastric cancer with suspected direct invasion to adjacent organs. Patient characteristics, related complications, long-term survival, and prognostic factors of cT4b gastric cancer were analyzed. RESULTS Postoperative mortality and morbidity rates of patients after MVR were 1.0 and 37.9%, respectively. R0 resection was achieved in 82.5% patients, all of whom had a significantly improved survival rate. Overall survival rates at 1 and 3 years were 78.3 and 47.7% for R0 resection and 46.6 and 14.3% for R1 resection, respectively (R0 vs. R1, P < 0.002). Multivariate analysis revealed that completeness of resection (R0) was an independent prognostic factor associated with longer survival. CONCLUSIONS In patients with cT4b gastric cancer, gastrectomy with MVR to achieve an R0 resection can be performed with acceptable postoperative morbidity and mortality rates and can have a positive impact on long-term survival.
Collapse
Affiliation(s)
- Kazuhito Mita
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan.
| | - Hideto Ito
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Toshio Katsube
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Ayaka Tsuboi
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Nobuyoshi Yamazaki
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Hideki Asakawa
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Takashi Hayashi
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| | - Keiichi Fujino
- Department of Surgery, New Tokyo Hospital, 1271 Wanagaya, Matudo, Chiba, Japan
| |
Collapse
|
19
|
Xiao H, Ma M, Xiao Y, Ouyang Y, Tang M, Zhou K, Hong Y, Tang B, Zuo C. Incomplete resection and linitis plastica are factors for poor survival after extended multiorgan resection in gastric cancer patients. Sci Rep 2017; 7:15800. [PMID: 29150634 PMCID: PMC5694005 DOI: 10.1038/s41598-017-16078-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022] Open
Abstract
The aim of this retrospective study was to analyze the morbidity, mortality, and survival rates of extended multiorgan resection (EMR) for locally advanced gastric cancer patients compared to gastrectomy alone and a palliative operation. 893 locally advanced gastric cancer patients without distant metastasis had surgery including gastrectomy alone (GA group, n = 798), EMR resection (EMR group, n = 75), and palliative operation (palliative gastrectomy or gastrojejunostomy (PO group, n = 20)). Postoperative mortality and complication rates in the EMR group were significantly higher than in the GA group (2.7% vs 0.4%, P = 0.010 and 25.3% vs 8.1%, P < 0.001, respectively), but similar in the PO group. The median survival time of the EMR group was significantly longer than in the PO group (27 months vs 11 months, P = 0.020), but significantly worse (P = 0.020) than in the GA group (44 months). Incompleteness of resection (R1) and linitis plastica were independent prognostic factors for survival in the EMR group. Three different gastric cancer surgeries led to different postoperative mortality and complication rates. EMR had a better survival rate compared with PO while GA had the longest survival time with the lowest mortality and complication rates.
Collapse
Affiliation(s)
- Hua Xiao
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Min Ma
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yanping Xiao
- Department of Admissions and Employment, Changsha Health Vocational College, Changsha, 410010, China
| | - Yongzhong Ouyang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Ming Tang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Kunyan Zhou
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yuan Hong
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Bo Tang
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Chaohui Zuo
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China.
| |
Collapse
|
20
|
Costa LBD, Toneto MG, Moreira LF. DO PROXIMAL AND DISTAL GASTRIC TUMOURS BEHAVE DIFFERENTLY? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:232-235. [PMID: 28076476 PMCID: PMC5225861 DOI: 10.1590/0102-6720201600040005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/06/2016] [Indexed: 01/03/2023]
Abstract
Background: Although the incidence of gastric (adenocarcinoma) cancer has been decreasing over time, it is still one of the most common malignancies worldwide, and proximal tumours tend to have a worse prognosis. Aim: To compare surgical outcomes and prognosis between proximal - excluding tumours of the cardia - and distal gastric cancer. Methods: Out of 293 cases reviewed - 209 with distal and 69 with proximal gastric cancer - were compared for clinical and pathological features, stage, surgical outcome, mortality and survival. Results: Statistically, there was no significant difference between patients in both groups regarding mortality (p=0.661), adjuvant chemotherapy (p 0.661), and radiation (p=1.000). However, there was significant difference in the degree of lymph node dissection employed (p=0.002) and the number of positive lymph nodes resected (p=0.038) between the two groups. The odds of death at five years for patients who had a D0 dissection was three times greater (odds ratio 2.78; (95%CI 1.33-5.82) than that for patients who had a D2 dissection, while for patients who had a D1 dissection the odds ratio was only 1.41 (95%CI 0.71-2.83) compared to D2-dissected patients. Conclusion: Although no significant differences were found between proximal and distal gastric cancer, the increased risk of death in D0- and D1-dissected patients clearly suggests an important role of radical D2 lymph node dissection in survival.
Collapse
Affiliation(s)
- Laurence Bedin da Costa
- Postgraduate Program in Medicine, Surgical Sciences, Universidade Federal do Rio Grande do Sul; RS, Brazil
| | - Marcelo Garcia Toneto
- Department of Surgery, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul; RS, Brazil
| | - Luis Fernando Moreira
- Department of Surgery, Hospital de Clínicas de Porto Alegre; Porto Alegre, RS, Brazil
| |
Collapse
|
21
|
Zu G, Zhang T, Li W, Sun Y, Zhang X. Impact of clinicopathological parameters on survival after multiorgan resection among patients with T4 gastric carcinoma: a systematic review and meta-analysis. Clin Transl Oncol 2017; 19:750-760. [PMID: 28054321 DOI: 10.1007/s12094-016-1600-3] [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] [Received: 09/12/2016] [Accepted: 12/16/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND The prognostic factors which can improve the overall survival (OS) of patients with T4 gastric carcinoma (GC) are still controversial: a meta-analysis was conducted to analyze the impact of clinicopathological parameters on survival after MOR among patients with T4 GC. METHODS A systematic search was performed. Odd risks (ORs) of patients with T4 GC were used to calculate the relationship between clinicopathological parameters and OS. RESULTS Nine studies involving 941 patients with T4 GC were identified. Well-moderate differentiation led to increased 1-, 3-, 5-year OS with an OR of 2.63, 1.58 and 1.45. Borrmann type I-II led to increased 1-, 3-year OS with an OR of 1.67 and 2.08. No lymph node metastasis led to increased 1-, 3-, 5-year OS with an OR of 7.16, 3.18 and 3.71. Total gastrectomy led to increased 1-, 3-year OS with an OR of 2.01 and 1.79. ≥2 Organs resected led to increased 1-, 3-year OS with an OR of 2.19 and 2.19. TNM stage II-III led to increased 1-, 3-year OS with an OR of 3.68 and 5.75. Curative resection led to increased 1-, 3-, 5-year OS with an OR of 4.46, 5.80 and 5.98. CONCLUSION Well-moderate differentiation, Borrmann type I-II, no lymph node metastasis, total gastrectomy, ≥2 organs resected, TNM stage II-III and curative resection were positive prognostic factors for OS of patients with T4 GC.
Collapse
Affiliation(s)
- G Zu
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian Shahekou District Southwest Road No. 826, Dalian, 116033, People's Republic of China.
| | - T Zhang
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian Shahekou District Southwest Road No. 826, Dalian, 116033, People's Republic of China
| | - W Li
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian Shahekou District Southwest Road No. 826, Dalian, 116033, People's Republic of China
| | - Y Sun
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian Shahekou District Southwest Road No. 826, Dalian, 116033, People's Republic of China
| | - X Zhang
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian Shahekou District Southwest Road No. 826, Dalian, 116033, People's Republic of China.
| |
Collapse
|
22
|
Tran TB, Worhunsky DJ, Norton JA, Squires MH, Jin LX, Spolverato G, Votanopoulos KI, Schmidt C, Weber S, Bloomston M, Cho CS, Levine EA, Fields RC, Pawlik TM, Maithel SK, Poultsides GA. Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative. Ann Surg Oncol 2015; 22 Suppl 3:S840-7. [PMID: 26148757 DOI: 10.1245/s10434-015-4694-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Resection of an adjacent organ during gastrectomy for gastric cancer is occasionally necessary to achieve margin clearance. The short- and long-term outcomes of this approach remain unclear. METHODS Patients who underwent gastric cancer resection in seven U.S. academic institutions from 2000 to 2012 were evaluated to compare perioperative morbidity, mortality, and survival outcomes, stratified by the need for and type of multivisceral resection (MVR). RESULTS Of 835 patients undergoing curative-intent gastrectomy, 159 (19 %) had MVR. The most common adjacent organs resected were the spleen (48 %), pancreas (27 %), liver segments 2/3 (14 %), and colon (13 %). As extent of resection increased (gastrectomy only, n = 676; MVR without pancreatectomy, n = 116; and MVR with pancreatectomy, n = 43), perioperative morbidity was higher: any complication (45, 60, 59 %, p = 0.012), major complication (17, 31, 33 %, p = 0.001), anastomotic leak (5, 11, 19 %, p < 0.001), and respiratory failure (9, 15, 22 %, p = 0.012). However, perioperative mortality did not significantly increase (30-day: 3, 4, 2 %, p = 0.74; 90-day: 6, 8, 9 %, p = 0.61). Overall survival after resection decreased as extent of resection increased (5-year: 42, 28, 6 %). After controlling for age, race, T stage, N stage, grade, margin status, perineural invasion, adjuvant therapy, and blood transfusion, MVR with pancreatectomy (HR 1.67, p = 0.044), but not MVR without pancreatectomy (HR 0.97, p = 0.759), remained an independent predictor of poor survival. CONCLUSION In this modern, multi-institutional cohort of gastric cancer patients, multivisceral resection was associated with higher perioperative morbidity but not significantly higher perioperative mortality. If concomitant pancreatectomy is anticipated, patients should be selected with extreme caution because long-term survival remains poor.
Collapse
Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - David J Worhunsky
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Malcolm Hart Squires
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Linda X Jin
- Department of Surgery, Barnes Jewish Hospital and The Alvin J. Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | | - Carl Schmidt
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Mark Bloomston
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Ryan C Fields
- Department of Surgery, Barnes Jewish Hospital and The Alvin J. Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - George A Poultsides
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.
| |
Collapse
|
23
|
Lowenfeld L, Datta J, Lewis RS, McMillan MT, Mamtani R, Damjanov N, Chandrasekhara V, Karakousis GC, Drebin JA, Fraker DL, Roses RE. Multimodality Treatment of T4 Gastric Cancer in the United States: Utilization Trends and Impact on Survival. Ann Surg Oncol 2015; 22 Suppl 3:S863-72. [DOI: 10.1245/s10434-015-4677-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Indexed: 01/19/2023]
|
24
|
Hu X, Cao L, Yu Y. Prognostic prediction in gastric cancer patients without serosal invasion: comparative study between UICC 7(th) edition and JCGS 13(th) edition N-classification systems. Chin J Cancer Res 2014; 26:596-601. [PMID: 25400426 DOI: 10.3978/j.issn.1000-9604.2014.10.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/09/2014] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE T-stage and N-stage have been proven to be the most important factors influencing survival in gastric cancer patients, and have been accepted for use in the Japanese Classification of Gastric Carcinoma (JCGC) and the Union International Cancer Control (UICC-TNM) staging systems. The purpose of this study was to compare the prognostic values of the different N classification systems in gastric cancer patients without serosal invasion. METHODS We retrospectively compared the clinicopathological results of 1,115 patients with primary gastric cancer who underwent curative gastric resection. RESULTS Serosal invasion was identified in 212 of 1,115 patients (19.0%), and it was associated with lymph node metastasis according to the JCGC(13th) (P<0.001) and TNM(7th) (P<0.001) systems. The 5-year survival rate for the serosal invasion-negative patients (78.2%) was significantly higher than that for the serosal invasion-positive patients (31.1%) (P<0.001). Multivariate Cox regression survival analysis showed that depth of invasion (P=0.013), 13(th) JCGC PN stage (P<0.001), and 7(th) TNM PN stage (P<0.001) were independent prognostic factors for serosal invasion-negative gastric cancer patients. CONCLUSIONS The prognosis of gastric cancer patients with serosal invasion is very poor. Both the 13(th) JCGC and 7(th) TNM N-staging systems were able to accurately estimate the prognosis of gastric cancer patients, but the 7(th) TNM system was simpler and easier to use.
Collapse
Affiliation(s)
- Xiang Hu
- Department of General Surgery, The First Affiliated Hospital, Dalian Medical University, Dalian 116011, China
| | - Liang Cao
- Department of General Surgery, The First Affiliated Hospital, Dalian Medical University, Dalian 116011, China
| | - Yi Yu
- Department of General Surgery, The First Affiliated Hospital, Dalian Medical University, Dalian 116011, China
| |
Collapse
|
25
|
Lee JH, Kim JG, Jung HK, Kim JH, Jeong WK, Jeon TJ, Kim JM, Kim YI, Ryu KW, Kong SH, Kim HI, Jung HY, Kim YS, Zang DY, Cho JY, Park JO, Lim DH, Jung ES, Ahn HS, Kim HJ. [Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 63:66-81. [PMID: 24561693 DOI: 10.4166/kjg.2014.63.2.66] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.
Collapse
Affiliation(s)
- Jun Haeng Lee
- Department of Gastroenterology, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul 156-861, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Lee JH, Kim JG, Jung HK, Kim JH, Jeong WK, Jeon TJ, Kim JM, Kim YI, Ryu KW, Kong SH, Kim HI, Jung HY, Kim YS, Zang DY, Cho JY, Park JO, Lim DH, Jung ES, Ahn HS, Kim HJ. Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach. J Gastric Cancer 2014; 14:87-104. [PMID: 25061536 PMCID: PMC4105383 DOI: 10.5230/jgc.2014.14.2.87] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 06/26/2014] [Indexed: 12/13/2022] Open
Abstract
Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.
Collapse
Affiliation(s)
- Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae G. Kim
- Department of Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University, College of Medicine, Seoul, Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Joo Jeon
- Department of Nuclear Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Mee Kim
- Department of Pathology, Inha University School of Medicine, Incheon, Korea
| | - Young Il Kim
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Young Zang
- Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Jae Yong Cho
- Department of Medical Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Oh Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sun Jung
- Department of Pathology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
27
|
Xiao L, Li M, Xu F, Ye H, Wu W, Long S, Li W, He Y. Extended multi-organ resection for cT4 gastric carcinoma: A retrospective analysis. Pak J Med Sci 2013; 29:581-5. [PMID: 24353581 PMCID: PMC3809257 DOI: 10.12669/pjms.292.2898] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/24/2012] [Accepted: 02/26/2013] [Indexed: 12/29/2022] Open
Abstract
Objective: Combined resection for locally advanced (T4) gastric cancer may result in high morbidity and mortality. The aim of this study was to evaluate the clinicopathologic characteristics to determine the prognostic factors for T4 gastric cancers. Methodology: A total of 463 consecutive patients with gastric cancers were enrolled in this study. Among them, 63 patients received combined resections. Various clinicopathologic factors influencing survival rates were evaluated. Survival rates were calculated according to the Kaplan-Meier method. Prognostic factors were evaluated by the univariate and multivariate analysis. Results: Thirty-one patients (49.2%) received one additional organ resection and 32 patients (50.8%) received two or more additional organ resections. Curative resection was performed in 49 patients (77.8%). Multivariate analysis identified curative resection (hazard ratio 0.330; 95 percent confidence interval, 0.139-0.784; P = 0.012) and tumor diameter (> 7 cm) (hazard ratio, 3.589; the 95 percent confidence interval, 1.425-9.037; P = 0.007) as independent prognostic factor for patients with T4 gastric cancer undergoing combined resection. Conclusions: The use of aggressive multi-organ resection was recommended for patients with T4 gastric carcinoma, with tumor diameter as a useful indicator. Patients with relatively small tumor diameter (≤ 7cm) could benefit from multi-organ resections.
Collapse
Affiliation(s)
- Longbin Xiao
- Longbin Xiao, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| | - Mingzhe Li
- Mingzhe Li, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| | - Fengfeng Xu
- Fengfeng Xu, Department of General Surgery I, Huangpu Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 510700
| | - Huishao Ye
- Huishao Ye, Department of Pharmacy, Huangpu Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 510700
| | - Wenhui Wu
- Wenhui Wu, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| | - Shuo Long
- Shuo Long, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| | - Wenfeng Li
- Wenfeng Li, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| | - Yulong He
- Yulong He, Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, 510700
| |
Collapse
|
28
|
Favacho BC, Costa CDS, Magalhães TC, Assumpção PPD, Ishak G. Adenocarcinoma gástrico T4b: experiência de 12 anos em Hospital Universitário. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:268-73. [DOI: 10.1590/s0102-67202013000400004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 08/19/2013] [Indexed: 11/21/2022]
Abstract
A neoplasia gástrica é doença heterogênea e multifatorial, com incidência e mortalidade variando geograficamente. Aproximadamente 60% dos diagnósticos em pacientes de países ocidentais ocorrem nos estádios III ou IV. Nestes doentes, o melhor tratamento consiste na realização de procedimento cirúrgico. OBJETIVO: Identificar os aspectos epidemiológicos de pacientes diagnosticados com adenocarcinoma gástrico T4b. MÉTODOS: Estudo observacional, transversal, retrospectivo, de fonte secundária, dos pacientes diagnosticados com adenocarcinoma gástrico T4b através de estadiamento patológico. Foram analisados 815 prontuários, sendo 27 pacientes estudados. As variáveis investigadas foram: aspectos demográficos, principais queixas, fatores de risco, acesso ao serviço de saúde, aspectos cirúrgicos, morbidade, mortalidade e sobrevida. RESULTADOS: Vinte e dois eram homens (81,5%) e cinco mulheres (18,5%) com idade variando de 38 a 87 e média de 58,78 anos. O tempo de acesso ao serviço, em meses, variou de 1 a 120, com média de 12,5. Os sinais e sintomas mais prevalentes foram: perda de peso 23 (85,2%), epigastralgia 22 (81,5%), vômitos 16 (59,3%) e plenitude gástrica 12 (44,4%). A frequência de acometimento das estruturas adjacentes foi: pâncreas oito (29,6%), fígado sete (25,9%), cólon transverso seis (22,2%), intestino delgado seis (22,2%), mesocólon três (11,1%), baço um (3,7%) e vesícula biliar um (3,7%). Morbidades pós-operatórias ocorreram em 51,85% dos pacientes. Houve associação significativa entre mortalidade cirúrgica e ocorrência de fístula/deiscência, choque séptico e sangramento. A sobrevida ao final de seis meses foi de 63,27%. CONCLUSÃO: A média do tempo entre início dos sintomas e acesso ao serviço de saúde especializado foi elevada. Mais da metade dos pacientes apresentaram morbidades pós-operatórias. Os pacientes que apresentaram fístula/deiscência, sangramentos e choque séptico tiveram associação significativa com mortalidade cirúrgica. A sobrevida ao final de seis meses foi de 63,27%.
Collapse
|
29
|
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: 1.5] [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.
Collapse
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.
| |
Collapse
|
30
|
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.
Collapse
Affiliation(s)
- Andrew M Blakely
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | | |
Collapse
|
31
|
Sakamoto Y, Sakaguchi Y, Sugiyama M, Minami K, Toh Y, Okamura T. Surgical indications for gastrectomy combined with distal or partial pancreatectomy in patients with gastric cancer. World J Surg 2013; 36:2412-9. [PMID: 22699747 DOI: 10.1007/s00268-012-1681-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The purpose of this study was to clarify the surgical indications for gastrectomy combined with distal or partial pancreatectomy (GP) in patients with gastric cancer. METHODS From January 1994 to December 2009, 29 patients with primary gastric cancer surgically invading the pancreas without distant organ metastasis underwent GP for R0 resection. The patients' characteristics, surgical data, and clinicopathological features were used for the analysis of survival and prognostic factors. RESULTS The median disease-free survival and median survival time (MST) of all patients were 15 and 30 months, respectively. Only pN3 status (characterized by 7 or more pathologically metastatic lymph nodes) according to the Japanese Classification of Gastric Carcinoma, 14th edition, was shown to be a prognostic factor in a multivariate analysis. The MST of the patients with pN3 and the other patients were 12 and 51 months, respectively (p < 0.001). CONCLUSIONS We suggest that pancreas invasion should not be considered a contraindication for gastrectomy and that patients with a small number of lymph node metastases (six or fewer) might be candidates for GP in the case of gastric cancer that requires pancreatectomy for R0 resection.
Collapse
Affiliation(s)
- Yasuo Sakamoto
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan.
| | | | | | | | | | | |
Collapse
|
32
|
Küçükkartallar T, Gündeş E, Yılmaz H, Aksoy F. A case of multiorgan resection for locally advanced stomach cancer. ULUSAL CERRAHI DERGISI 2013; 29:31-2. [PMID: 25931839 DOI: 10.5152/ucd.2013.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 11/10/2011] [Indexed: 11/22/2022]
Abstract
Extensive surgical resection may be required in locally advanced gastric cancers, with involvement of other organs. Our purpose was to present a case where vascular reconstruction was performed during multiple organ resections in a patient with locally advanced gastric cancer. An emergent laparotomy was performed on a patient who presented with upper gastrointestinal system hemorrhage; and he was diagnosed with locally advanced gastric cancer. Total gastrectomy, D II dissection, pancreaticoduodenectomy, transverse colectomy and end-to-end anastomosis were performed. Additionally, the superior mesenteric vein was partially excised and re-implanted to the portal vein. Neither recurrence nor distant metastasis was observed during the post-operative follow-up. Adjacent organ resections may be necessary for a curative treatment in locally advanced gastric cancer. In addition, partial resection and reconstruction may be required for extensive vascular invasion.
Collapse
Affiliation(s)
- Tevfik Küçükkartallar
- Department of General Surgery, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey
| | - Ebubekir Gündeş
- Department of General Surgery, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey
| | - Hüseyin Yılmaz
- Department of General Surgery, Selçuk University Faculty of Medicine, Konya, Turkey
| | - Faruk Aksoy
- Department of General Surgery, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey
| |
Collapse
|
33
|
Brar SS, Seevaratnam R, Cardoso R, Yohanathan L, Law C, Helyer L, Coburn NG. Multivisceral resection for gastric cancer: a systematic review. Gastric Cancer 2012; 15 Suppl 1:S100-7. [PMID: 21785926 DOI: 10.1007/s10120-011-0074-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/26/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The overall prognosis and survival of patients with advanced gastric cancer is generally poor. One of the most powerful predictors of outcomes in gastric cancer surgery is an R0 resection. However, the extent of the required surgical resection and the additional benefit of multivisceral resection (MVR) are controversial. METHODS Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers. RESULTS Seventeen studies were included in this review. Among the 1343 patients who underwent MVR, overall complication rates ranged from 11.8 to 90.5%. Perioperative mortality was found to be 0-15%. Pathological T4 disease was confirmed in 28.8-89% of patients. R0 resection and extent of nodal involvement were important predictors of survival in patients undergoing MVR. Patient outcomes may also be affected by the number of organs resected. CONCLUSIONS Gastrectomy with MVR can be safely pursued in patients with locally advanced gastric cancer to achieve an R0 resection. MVR may not be beneficial in patients with extensive nodal disease.
Collapse
Affiliation(s)
- Savtaj S Brar
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Suite T2-60, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | | | | | | | | | | | | |
Collapse
|
34
|
Lai KK, Fang WL, Wu CW, Huang KH, Chen JH, Lo SS, Li AFY. Surgical Impact on Gastric Cancer with Locoregional Invasion. World J Surg 2011; 35:2479-84. [DOI: 10.1007/s00268-011-1246-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
35
|
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 2011; 19:494-501. [DOI: 10.1245/s10434-011-1987-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Indexed: 12/31/2022]
|
36
|
Mita K, Ito H, Fukumoto M, Murabayashi R, Koizumi K, Hayashi T, Kikuchi H. Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer. Am J Surg 2011; 203:107-11. [PMID: 21474116 DOI: 10.1016/j.amjsurg.2010.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 12/07/2010] [Accepted: 12/07/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Extended multiorgan resection (EMR) for locally advanced (T4) gastric cancer remains controversial. The aim of this study was to evaluate the effectiveness of this approach with regard to morbidity, mortality, and survival. METHODS Between 2005 and 2009, 41 patients underwent aggressive surgery for clinical T4 gastric cancer. Univariate and multivariate analyses were used to identify prognostic factors for surgical outcomes and survival in these patients. RESULTS Curative resection was performed in 29 patients (70.7%); postoperative morbidity and mortality rates were 17.1% and 4.9%, respectively. The survival rate in R0 resection patients was significantly longer than that in patients undergoing R1 or R2 resection. Multivariate analysis identified resectability and tumor size (≥10 cm) as independent prognostic factor for patients with T4 gastric cancer undergoing combined resection. CONCLUSIONS EMR should be performed for patients with T4 gastric cancer in whom curative resection can be used.
Collapse
Affiliation(s)
- Kazuhito Mita
- Department of Surgery, Shin-Tokyo Hospital, Chiba, Japan.
| | | | | | | | | | | | | |
Collapse
|
37
|
Cheng CT, Tsai CY, Hsu JT, Vinayak R, Liu KH, Yeh CN, Yeh TS, Hwang TL, Jan YY. Aggressive surgical approach for patients with T4 gastric carcinoma: promise or myth? Ann Surg Oncol 2011; 18:1606-14. [PMID: 21222167 DOI: 10.1245/s10434-010-1534-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical outcomes of multiorgan resection (MOR) for T4 gastric carcinoma reported in the literature are widely variable. We herein report a large surgical series of T4 gastric carcinoma. METHODS One hundred seventy-nine patients with cT4 gastric carcinoma were recruited onto the study. Patient characteristics, surgical strategy and related complications, long-term survival, and prognostic factors of T4 gastric carcinoma were analyzed. RESULTS Of 179 cT4 gastric carcinoma, there were 57 cT4 (pT3) with MOR, 91 pT4 with MOR, and 31 cT4 without MOR. pT4 with MOR were more likely to be associated with nodal metastasis, cellular dedifferentiation, and lymphoperineural infiltration compared to those of pT0-3 (P < 0.01 for all). For 91 pT4 with MOR, their surgical mortality and morbidity rates were 4.4 and 28.6%, respectively; their 1-, 3-, and 5-year overall survival rates were 55.2, 22.4, and 12.2%, respectively. The long-term survival of cT4 (pT3) with MOR was superior to pT4 with MOR (P = 0.006) and cT4 without MOR (P = 0.004). There was a striking difference between pT4 with MOR, R0 and pT4 with MOR, and R1 or R2 (P = 0.007). By means of multivariate analysis, lymph node status, liver invasion, and positive surgical margin were independent prognostic factors. CONCLUSIONS Aggressive surgical management of pT4 gastric carcinoma should be limited to patients without adverse prognostic factors such as advanced nodal involvement and pancreatic invasion.
Collapse
Affiliation(s)
- Chi-Tung Cheng
- Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taipei, Taiwan
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Park JH, Hyung WJ, Choi SH, Noh SH. Should direct mesocolon invasion be included in T4 for the staging of gastric cancer? J Surg Oncol 2010; 101:205-8. [PMID: 20082356 DOI: 10.1002/jso.21476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES One of the sites most frequently invaded by gastric cancer is the mesocolon; however, the UICC does not mention this anatomical site as an adjacent structure involved in gastric cancer. The purpose of this study was to characterize and classify mesocolon invasion from gastric cancer. METHODS We examined 806 patients who underwent surgery for advanced gastric carcinoma from 1992 to 2007 at the Department of Surgery, Gangnam Severance Hospital, Korea. Among these, patients who showed macroscopically direct invasion into the mesocolon were compared to other patients with advanced gastric cancer. RESULTS The curability, number and extent of nodal metastasis, and the survival of the mesocolon invasion group were significantly worse than these factors in the T3 group. However, the survival of the mesocolon invasion group after curative resection was much better than that of patients who had incurable factors. CONCLUSIONS Mesocolon invasion should be included in T4 for the staging of gastric cancer.
Collapse
Affiliation(s)
- Jung Hoon Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
39
|
Kim JH, Jang YJ, Park SS, Park SH, Kim SJ, Mok YJ, Kim CS. Surgical outcomes and prognostic factors for T4 gastric cancers. Asian J Surg 2010; 32:198-204. [PMID: 19892622 DOI: 10.1016/s1015-9584(09)60395-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE In locally advanced gastric carcinomas that have invaded adjacent organs, the prognosis is poor. When combined resections are performed in T4 gastric cancers, a high morbidity rate is reported and it is inconclusive as to whether or not there is an improvement in the survival rate. We investigated surgical outcomes and analysed the prognostic factors for T4 gastric cancers. PATIENTS AND METHODS Between January 1992 and December 2000, 132 patients underwent surgery for T4 gastric cancer; they were divided into three groups: combined resections in group I, gastrectomy alone in group II, and resections not performed but palliative gastrojejunostomy or intraperitoneal chemotherapy in group III. Surgical outcomes and clinicopathologic factors were compared and prognostic factors were evaluated. RESULTS Among the three groups, statistically significantly different factors were tumour location, Borrmann type, tumour size, distant metastasis and peritoneal metastasis. The most commonly resected organ was the transverse colon, and 14 post-operative morbidities developed. In the multivariate analysis, the treatment group and curability were proved to be independent prognostic factors. CONCLUSION In patients with T4 gastric carcinoma, an aggressive surgical approach can be beneficial when curative resection is performed. If curative resection is not possible, palliative resection can be performed for a better quality of life.
Collapse
Affiliation(s)
- Jong-Han Kim
- Department of Surgery, Korea University College of Medicine, Ansan City, South Korea.
| | | | | | | | | | | | | |
Collapse
|
40
|
Jeong O, Choi WY, Park YK. Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs. J Surg Oncol 2009; 100:115-20. [PMID: 19475581 DOI: 10.1002/jso.21306] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Proper patient selection for multi-organ resection in T4 gastric carcinoma remains controversial. Our aim was to investigate which patients might benefit from multi-organ resection. METHODS Among 1,775 consecutive patients receiving gastric cancer surgery, 71 had adjacent organ invasion. Short- and long-term surgical outcomes and associations between clinicopathological factors and overall survival were investigated. RESULTS Forty-seven patients underwent curative surgery with multi-organ resection, and 24 underwent non-curative surgery, with or without multi-organ resection. Postoperative morbidity and mortality rates were 31.7% and 3.3%, respectively. Patients receiving curative surgery via multi-organ resection survived longer than those without (MST, 31.5 months vs. 19.1 months, P = 0.046). Multi-organ resection did not affect survival when performed in non-curative surgery. N3 lymph node metastasis was an independent prognostic factor for poor outcome (HR = 3.89, 95% CI = 1.40-10.83) in curatively resected patients; patients with N3 lymph node metastasis showed similar survival to patients receiving non-curative surgery. CONCLUSION Multi-organ resection should be performed only when no incurable factors are present, and R0 resection is most likely. Multi-organ organ resection does not, however, seem to be effective in patients with N3 lymph node metastasis, even when curative resection is performed.
Collapse
Affiliation(s)
- Oh Jeong
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University College of Medicine, Jeollanam-do, Korea
| | | | | |
Collapse
|
41
|
Sun Z, Zhu GL, Lu C, Guo PT, Huang BJ, Li K, Xu Y, Li DM, Wang ZN, Xu HM. The impact of N-ratio in minimizing stage migration phenomenon in gastric cancer patients with insufficient number or level of lymph node retrieved: results from a Chinese mono-institutional study in 2159 patients. Ann Oncol 2009; 20:897-905. [PMID: 19179553 DOI: 10.1093/annonc/mdn707] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Previous studies indicate that N-ratio has significant superiority in minimizing 'stage migration' for patients with >15 lymph nodes retrieved. Whether the result is applicable to patients with < or =15 lymph nodes retrieved is still in question. PATIENTS AND METHODS Overall survival rates of 2159 gastric cancer patients who underwent radical resection were compared between patients with different number and level of lymph nodes retrieved according to pN [International Union Against Cancer (Union Internationale Contre le Cancer)/AJCC N stage], n (JGCA N stage) and rN (N-ratio) staging system. RESULTS Patient number was significantly different between insufficient and sufficient number or level retrieved group in pN and n system, respectively, but not in rN system, while overall survival rates were not significantly different between those groups. The 5-year survival rates of patients with insufficient nodes retrieved were significantly lower than those with sufficient nodes retrieved in pN and n system, but not in rN system. The hazard risk for patients with insufficient nodes retrieved was significantly higher than that for patients with sufficient nodes retrieved in pN and n system, but not in rN system. CONCLUSION The rN stage has more potential advantages in minimizing stage migration phenomenon for patients with insufficient number or level of lymph nodes retrieved.
Collapse
Affiliation(s)
- Z Sun
- Department of Surgical Oncology, First Affiliated Hospital of China Medical University, Shenyang, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Ryu SY, Joo JK, Park YK, Kim YJ, Kim SK, Lee JH, Kim DY. Prognosis of gastric carcinoma invading the mesocolon. Asian J Surg 2008; 31:179-84. [PMID: 19010759 DOI: 10.1016/s1015-9584(08)60082-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The prognosis is poor when gastric carcinoma invades adjacent organs. We evaluated the outcome indicators in gastric carcinoma patients with mesocolon invasion. METHODS We reviewed the hospital records of 169 gastric carcinoma patients with mesocolon invasion seen between 1986 and 2000 at Chonnam National University Hospital. RESULTS The curative resection rate in gastric carcinoma patients with mesocolon invasion was 29.6% (50/169). Using Cox's proportional hazards regression model, curability was the only independent, statistically significant prognostic parameter (risk ratio, 1.48; 95% confidence interval, 0.902.46; p < 0.05). The 5-year survival rate was higher for patients who underwent curative resection (15.5%) than for those who underwent non-curative resection (2.6%; p < 0.001). The 5-year survival rate was higher for patients who underwent resection (7.3%) than for those who did not (bypass and exploration groups, 5.1% and 0%, respectively; p < 0.001). CONCLUSION The results showed improved survival of gastric carcinoma patients with mesocolon invasion who underwent curative resection compared to those who did not. Improving the prognosis for patients with mesocolon invasion requires curative resection.
Collapse
Affiliation(s)
- Seong Yeob Ryu
- Division of Gastroenterologic Surgery, Departments of Surgery, National University Medical School, Gwangju, Korea
| | | | | | | | | | | | | |
Collapse
|
43
|
Oñate-Ocaña LF, Becker M, Carrillo JF, Aiello-Crocifoglio V, Gallardo-Rincón D, Brom-Valladares R, Herrera-Goepfert R, Ochoa-Carrillo F, Beltrán-Ortega A. Selection of best candidates for multiorgan resection among patients with T4 gastric carcinoma. J Surg Oncol 2008; 98:336-42. [PMID: 18646043 DOI: 10.1002/jso.21118] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to define prognostic factors to select those patients with best chance to benefit from multiorgan resection. MATERIALS AND METHODS A cohort of patients with T4 GC treated in a 19-year period. Surgical morbidity-associated factors were identified by logistic regression analysis. Prognostic factors were defined by Kaplan-Meier and Cox methods. RESULTS Seven hundred eighteen patients were included (gastrectomy performed in 169). Surgical morbidity and mortality were 39% and 10.7%, respectively. Surgical morbidity were associated to extent of gastrectomy, age, serum albumin, and lymphocyte count (P = 0.0001). Presence of metastasis (hazard ratio [HR], 1.68; 95% confidence interval [95% CI], 1.19-2.36), albumin <3 g/dl plus lymphocytes <1,000 cells/mm(3) (HR, 2.9; 95% CI, 1.8-4.6), presence of ascites (HR, 2.1; 95% CI, 1.06-4.2), age >or=50 (HR, 1.37; 95% CI, 1.02-1.8), and unresectable disease (HR, 2.6; 95% CI, 1.7-4.1) defined poor survival (P = 0.00001). CONCLUSION Performing a multiorgan resection must be balanced between chances for long-term survival and surviving a potentially fatal operation. Absence of metastases, serum albumin levels >3 g/dl, and accomplishment of R0 resection select patients with high probability of benefit from multiorgan resection.
Collapse
Affiliation(s)
- Luis F Oñate-Ocaña
- Clínica de Neoplasias Gástricas, Departamento de Gastroenterología, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico.
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Ozer I, Bostanci EB, Orug T, Ozogul YB, Ulas M, Ercan M, Kece C, Atalay F, Akoglu M. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg 2008; 198:25-30. [PMID: 18823618 DOI: 10.1016/j.amjsurg.2008.06.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 06/25/2008] [Accepted: 06/25/2008] [Indexed: 01/01/2023]
Abstract
BACKGROUND Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival. METHODS Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated. RESULTS Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival. CONCLUSIONS For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.
Collapse
Affiliation(s)
- Ilter Ozer
- Turkiye Yuksek Ihtisas Training and Research Hospital, Mamak, Ankara, Turkey.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Tokunaga M, Ohyama S, Nunobe S, Hiki N, Fukunaga T, Seto Y, Yamaguchi T. Advanced gastric cancer with a duplicated hepatic artery: preoperative diagnostic value of multidetector-row computed tomography for surgical resection. Gastric Cancer 2008; 10:191-5. [PMID: 17922099 DOI: 10.1007/s10120-007-0430-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2006] [Accepted: 05/30/2007] [Indexed: 02/07/2023]
Abstract
A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fiberscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.
Collapse
Affiliation(s)
- Masanori Tokunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | | | | | | | | | | | | |
Collapse
|
46
|
McKay A, Sutherland FR, Bathe OF, Dixon E. Morbidity and mortality following multivisceral resections in complex hepatic and pancreatic surgery. J Gastrointest Surg 2008; 12:86-90. [PMID: 17710505 DOI: 10.1007/s11605-007-0273-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
Complex multivisceral resections in major hepatic and pancreatic surgery are relatively infrequent, and information regarding the morbidity and mortality associated with such resections is scant. The purpose of this paper is to describe the outcomes following such aggressive surgical treatment. A retrospective review of the outcomes following multiorgan resection in the setting of major liver or pancreatic resection was conducted from 2002 until July 2006. Patients who had a major hepatic or pancreatic resection plus resection of at least one other organ were included. The primary outcome measures analyzed were the postoperative morbidity and mortality. Secondary outcomes included recurrence rates and survival. Twenty-seven patients met the inclusion criteria. There were two postoperative deaths (7%). Complications occurred in 59% of patients. Complications were minor in 26% and severe in 33%. Complications were more frequent in older patients and in patients with pancreatic resections. Mortality was significantly increased in the setting of a pancreaticoduodenectomy. These more aggressive procedures should be considered to carry a higher risk of complications, particularly in patients undergoing pancreaticoduodenectomies. Patients should be selected carefully when undertaking complex multivisceral resections in major hepatic and pancreatic surgery.
Collapse
Affiliation(s)
- Andrew McKay
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | | | | |
Collapse
|
47
|
Shen JY, Kim S, Cheong JH, Kim YI, Hyung WJ, Choi WH, Choi SH, Wang LB, Noh SH. The impact of total retrieved lymph nodes on staging and survival of patients with pT3 gastric cancer. Cancer 2007; 110:745-51. [PMID: 17614104 DOI: 10.1002/cncr.22837] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The incidence of lymph node metastasis is high in patients who have pT3 gastric cancer. However, the impact of total retrieved lymph nodes (tLNs) on staging and survival of these patients is not clear. METHODS For this study, the authors examined 1895 patients with pT3 gastric cancer who underwent surgery at Yonsei University Medical College from January 1987 to June 2000. RESULTS Four hundred sixty of 1895 patients (24.3%) were diagnosed with pT3N0 gastric cancer. Patients who had < 31 tLNs (25th percentile) had less advanced lymph node (N) stage than the other patients (P < .001). Lymph node metastasis had a positive association with the number of tLNs in a logistic regression analysis (P < .001; hazards ratio, 1.014; 95% confidence interval, 1.006-1.021). With a median follow-up of 61.1 months, the overall 10-year survival rate (10-YSR) was 42.8%. Patients with pT3N0 disease who had < 31 tLNs had a 10-YSR of only 55.4%. Although this 10-YSR did not differ significantly from the rate for patients with N0 disease who had > or =31 tLNs (65.8%; P = .108), it approached the rate for the N1 group (53.3%; P = .207). In multivariable analyses, the number of tLNs emerged as an independent prognostic predictor in patients with pT3N2 and pT3N3 disease, but not in patients with pT3N0 or pT3N1 disease. CONCLUSIONS Increasing numbers of tLNs may improve the accuracy of staging in patients who have pT3 gastric cancer. Because preoperative lymph node staging is difficult, a thorough lymph node dissection is mandatory in all serosa-positive patients.
Collapse
Affiliation(s)
- Jia Yun Shen
- Department of Surgery, Yonsei University College of Medicine, Seodaemun-Gu, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Káposztás Z, Kalmár K, Cseke L, Illényi L, Kelemen D, Horváth OP. Prognostic factors in the surgical treatment of gastric cancer--10 years experience. Magy Seb 2007; 60:71-8. [PMID: 17649847 DOI: 10.1556/maseb.60.2007.2.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In spite of the increase in radicality and extended resections, the prognosis of gastric cancer is very poor. Surgical resection is the only effective therapy. The morbidity and mortality of surgical interventions decreased during the last years. METHOD The aim of this study was to evaluate the prognostic effect of different factors on survival of gastric cancer. A retrospective study of 483 patients with gastric cancer was performed. Data were collected from January 1993 to December 2002. There were 380 resections, 267 (70,2%) total gastrectomies, 93 (24.8%) distal resections and 20 (5.2%) proximal resections. Epidemiological factors, tumour and treatment related parameters were analysed. Kaplan-Meier method was used to assess survival and Cox regression analysis to evaluate the effect of prognostic factors on survival. RESULTS The rate of R0 resections was 73.4% for total gastrectomy, and 73% for distal gastrectomy. The five-year overall survival of the entire population was 26.08%, 36.2% of the resected patients and 69.05% of curative resections. In concordance with literature findings, radicality of resection, depth of tumour invasion and lymph node metastases proved to be the most powerful independent prognostic factors. CONCLUSION Prognosis of gastric cancer can be remarkably improved by a complete resection of the tumour and its lymphatic drainage, even if extension of the resection is needed.
Collapse
Affiliation(s)
- Zsolt Káposztás
- Pécsi Tudományegyetem, Orvostudományi és Egészségtudományi Centrum, Altálnos Orvostudományi Kar, Sebészeti Klinika
| | | | | | | | | | | |
Collapse
|
49
|
Al-Moundhri MS, Al-Bahrani B, Burney IA, Nirmala V, Al-Madhani A, Al-Mawaly K, Al-Nabhani M, Thomas V, Ganguly SS, Grant CS. The prognostic determinants of gastric cancer treatment outcome in Omani Arab patients. Oncology 2006; 70:90-6. [PMID: 16601367 DOI: 10.1159/000092584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Accepted: 11/20/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric cancer is the most common cancer in Oman and a leading cause of cancer death. The variation in survival rates between countries and ethnic groups has been attributed to early detection policies, differences in clinicopathological features, treatment approaches, and biological characteristics. There were no previous reports on gastric cancer from Oman and very few studies on Asian Arabs. AIM To evaluate the impact of clinicopathological and treatment variables on the survival prospects of Omani Arab patients diagnosed with gastric cancer. METHODS The medical records of 339 Omani Arab patients diagnosed with invasive gastric adenocarcinoma during the period 1993-2004 were retrospectively reviewed. The relative importance of clinicopathological features and surgical and medical treatments were assessed using univariate and multivariate analyses. RESULTS Most patients had distal ulcerating-type gastric cancer and presented at advanced stages. The median survival time for the entire cohort was 12 months (95% CI 9.7-14.4) with a 5-year overall survival rate of 16.7%. On univariate analysis of 237 patients who underwent surgical resection, the following positive prognostic factors emerged as significant: early overall TNM stage, early T stage, negative lymph nodes, tumor size <5 cm, ulcerating macroscopic appearance, and curative surgical attempt. The independent prognostic factors on multivariate analysis were T stage and lymph node involvement. CONCLUSION The overall T and N stages are the most important determining factor for survival in Omani Arab patients. More efforts need to be made for the early detection of gastric cancer in developing countries such as Oman, while continuing to employ the standard surgical and medical treatments.
Collapse
Affiliation(s)
- M S Al-Moundhri
- Medical Oncology Unit, Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University (SQU), Muscat, Oman.
| | | | | | | | | | | | | | | | | | | |
Collapse
|