Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

Are Palliative Interventions Worth the Risk in Advanced Gastric Cancer? A Systematic Review

Background: Less than 25% of gastric cancers (GC) are discovered early, leading to limited treatment options and poor outcomes (27.8% mortality, 3.7% 5-year survival). Screening programs have improved cure rates, yet post-diagnosis treatment guidelines remain unclear (systemic chemotherapy versus surgery). The optimal type of palliative surgery (palliative gastrectomy (PG), surgical bypass (SB), endoscopic stenting (ES)) for long-term outcomes is also debated. Methods: A literature review was conducted using PubMed, MEDLINE, and EMBASE databases along with Google Scholar with the search terms "gastric cancer" and "palliative surgery" for studies post-1985. From the initial 1018 articles, multiple screenings narrowed it to 92 articles meeting criteria such as "metastatic, stage IV GC", and intervention (surgery or chemotherapy). Data regarding survival and other long-term outcomes were recorded. Results: Overall, there was significant variation between studies but there were similarities of the conclusions reached. ES provided quick symptom relief, while PG showed improved overall survival (OS) only with adjuvant chemotherapy in a selective population. PG had higher mortality rates compared to SB, with ES having a reported 0% mortality, but OS improved with chemotherapy across both SB and PG. Conclusions: Less frail patients may experience an improvement in OS with palliative resection under limited circumstances. However, operative intervention without systemic chemotherapy is unlikely to demonstrate a survival benefit. Further research is needed to explore any correlations.

The prognostic role of palliative gastrectomy in advanced gastric cancer: a systematic review and meta-analysis

BACKGROUND

The effectiveness of palliative gastrectomy for advanced GC remains a topic of debate. This study sought to establish whether palliative gastrectomy has an impact on prolonging survival.

METHODS

We carried out systematic searches in PubMed, Cochrane Library, Web of Science, and the EMBASE databases from database inception to July 2023 to gather studies that examined the connection between palliative gastrectomy and the prognosis of advanced GC. The study employed overall survival as the primary outcome, with the hazard ratio serving as the selected parameter to gauge the association. Subgroup analyses were performed to delve into potential differences within the included studies, categorizing them by study region and sample size in order to examine possible sources of heterogeneity. The stability of individual studies was assessed through sensitivity analysis. The analysis included 20 articles, encompassing a total of 23,061 patients.

RESULTS

According to the meta-analysis results, patients who underwent palliative gastrectomy exhibited a noteworthy enhancement in overall survival (HR: 1.49; 95% CI: 1.12-1.99; P = 0.006) in comparison to those who did not receive this procedure. There was no association between the type of surgery and the length of hospital stay, as revealed by the analysis (HR = -0.02; 95% CI: -0.84-0.81; P = 0.970).

CONCLUSIONS

Based on this meta-analysis, patients with advanced gastric cancer who underwent palliative gastrectomy may experience an extended survival duration without a significant prolongation of their hospitalization.

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes

BACKGROUND

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population.

PATIENTS AND METHODS

Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated.

RESULTS

Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months.

CONCLUSIONS

Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

A prognostic nomogram to predict the cancer-specific survival of patients with initially diagnosed metastatic gastric cancer: a validation study in a Chinese cohort

BACKGROUND

Few studies have been designed to predict the survival of Chinese patients initially diagnosed with metastatic gastric cancer (mGC). Therefore, the objective of this study was to construct and validate a new nomogram model to predict cancer-specific survival (CSS) in Chinese patients.

METHODS

We collected 328 patients with mGC from Northern Jiangsu People's Hospital as the training cohort and 60 patients from Xinyuan County People's Hospital as the external validation cohort. Multivariate Cox regression was used to identify risk factors, and a nomogram was created to predict CSS. The predictive performance of the nomogram was evaluated using the consistency index (C-index), the calibration curve, and the decision curve analysis (DCA) in the training cohort and the validation cohort.

RESULTS

Multivariate Cox regression identified differentiation grade (P < 0.001), T-stage (P < 0.05), N-stage (P < 0.001), surgery (P < 0.05), and chemotherapy (P < 0.001) as independent predictors of CSS. Nomogram of chemotherapy regimens and cycles was also designed by us for the prediction of mGC. Thus, these factors are integrated into the nomogram model: the C-index value was 0.72 (95% CI 0.70-0.85) for the nomogram model and 0.82 (95% CI 0.79-0.89) and 0.73 (95% CI 0.70-0.86) for the internal and external validation cohorts, respectively. Calibration curves and DCA also demonstrated adequate fit and ideal net benefit in prediction and clinical applications.

CONCLUSIONS

We established a practical nomogram to predict CSS in Chinese patients initially diagnosed with mGC. Nomograms can be used to individualize survival predictions and guide clinicians in making therapeutic decisions.

Intraoperative assessment of the curative potential to predict survival after gastric cancer resection: A national cohort study

BACKGROUND

The surgeon's intraoperative assessment of the curative potential of tumor resection following gastrectomy adds new information that could help clinicians and patients by predicting survival.

METHODS

All patients in Sweden undergoing gastric cancer resection between 2006 and 2018 were grouped according to a prospectively registered variable; the surgeon's intraoperative assessment of the curative potential of surgery: curative, borderline curative, or palliative. Factors affecting group allocation were analyzed with multivariable logistic regression, while survival was analyzed using multivariable Cox regression and the Kaplan-Meier method. Positive predictive value (PPV) and negative predictive value (NPV) were calculated.

RESULTS

Of 2341 patients undergoing gastric cancer resection, 1547 (71%) were deemed curative, 340 (15%) borderline curative, and 314 (14%) palliative (140 missing assessments). Advanced stage increased the risk of borderline curative resection (Stage III, odds ratio (OR) = 6.04, 95% confidence interval (CI) = 3.92-9.31), as did emergency surgery OR = 3.31 (1.74-6.31) and blood loss >500 mL; OR = 1.63 (1.06-2.49). Neoadjuvant chemotherapy and multidisciplinary team (MDT) discussion both decreased the risk of borderline curative resection, OR = 0.58 (0.39-0.87) and 0.57 (0.40-0.80), respectively. In multivariable Cox regression, the surgeon's assessment independently predicted worse survival for borderline curative (hazard ratio (HR) = 1.54, 95% CI = 1.29-1.83) and palliative resections (HR = 1.76, 95% CI = 1.45-2.19), compared to curative resections. The sensitivity of the surgeon's assessment of long-term survival was 96.7%. The PPV was 50.7% and the NPV was 92.1%.

CONCLUSION

The surgeon's intraoperative assessment of the curative potential of gastric cancer surgery may independently aid survival prediction and is analogous to prognostication by pathologic Staging. Advanced disease, emergency surgery, and a high intraoperative blood loss, increases the risk of a borderline curative or palliative resection. Conversely, neoadjuvant treatment and MDT discussion reduce the risk of borderline curative or palliative resection.

PALLIATIVE GASTRECTOMY VERSUS GASTRIC BYPASS FOR SYMPTOMATIC CLINICAL STAGE IV GASTRIC CANCER: A PROPENSITY SCORE MATCHING ANALYSIS

BACKGROUND

Patients with clinical stage IV gastric cancer may require palliative procedures to manage complications such as obstruction. However, there is no consensus on whether performing palliative gastrectomy compared to gastric bypass brings benefits in terms of survival.

AIMS

To compare the overall survival of patients with distal obstructive gastric cancer undergoing palliative surgical treatment, using propensity score matching analysis.

METHODS

Patients who underwent palliative bypass surgery (gastrojejunostomy or partitioning) and resection between the years 2009 and 2023 were retrospectively selected. Initial and postoperative clinicopathological variables were collected.

RESULTS

150 patients were initially included. The derived group (n=91) presented more locally invasive disease (p<0.01), greater degree of obstruction (p<0.01), and worse clinical status (p<0.01), while the resected ones (n= 59) presented more distant metastasis (p<0.01). After matching, 35 patients remained in each group. There was no difference in the incidence of postoperative complications, but the derived group had higher 90-day mortality (p<0.01). Overall survival was 16.9 and 4.5 months for the resected and derived groups, respectively (p<0.01). After multivariate analysis, hypoalbuminemia (hazard ratio - HR=2.02, 95% confidence interval - 95%CI 1.17-3.48; p=0.01), absence of adjuvant chemotherapy (HR=5.97; 95%CI 3.03-11.7; p<0.01), and gastric bypass (HR=3,28; 95%CI 1.8-5.95; p<0.01) were associated with worse survival.

CONCLUSIONS

Palliative gastrectomy was associated with greater survival and lower postoperative morbidity compared to gastric bypass. This may be due to better local control of the disease, with lower risks of complications and better effectiveness of chemotherapy.

Role of reduction gastrectomy in patients with gastric cancer with a single non-curable factor: Supplementary analysis of REGATTA trial

Background

REGATTA trial failed to demonstrate the survival benefit of reduction gastrectomy in patients with advanced gastric cancer with a single non-curable factor. However, a significant interaction was found between the treatment effect and tumor location in the subset analysis. Additionally, the treatment effect appeared to be different between Japan and Korea. This supplementary analysis aimed to elucidate the effect of reduction surgery based on tumor location and country.

Methods

Multivariable Cox regression analyses in each subgroup were performed to estimate the hazard ratio (HRadj), including the following variables as explanatory variables: country, age, sex, incurable factor, cT, cN, primary tumor, performance status, histological type, and macroscopic type.

Results

Patients (95 in Japan and 80 in Korea) were randomized to chemotherapy alone (86 patients) or gastrectomy plus chemotherapy (89 patients). The subgroup analysis according to the country revealed a worse overall survival in gastrectomy plus chemotherapy arm in Japan (hazard ratio: 1.32, 95% confidence interval: 0.85-2.05), but not in Korea (hazard ratio: 0.85.95% confidence interval: 0.52-1.40). Overall survival was better in distal gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 0.69, 95% confidence interval: 0.42-1.13), and worse in total gastrectomy plus chemotherapy compared with chemotherapy alone (hazard ratio = 1.34, 95% CI: 0.93-1.94), which was more remarkable in Korea than in Japan.

Conclusions

Primary chemotherapy is a standard of care for advanced gastric cancer; however, the survival benefits from reduction by distal gastrectomy remained controversial.

Palliative Gastrectomy Improves the Survival of Patients with Metastatic Early-Onset Gastric Cancer: A Retrospective Cohort Study

Background: Recent studies have found that patients with incurable gastric cancer might benefit from palliative gastrectomy, but the impact of palliative gastrectomy on metastatic early-onset gastric cancer (mEOGC) patients remains unclear. Methods: We analyzed mEOGC patients enrolled in the Surveillance, Epidemiology, and End Results registry from January 2004 to December 2018. Propensity score matching (PSM) analysis with 1:1 matching and the nearest-neighbor matching method were used to ensure well-balanced characteristics between the groups of patients with palliative gastrectomy and those without surgery. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to evaluate the overall survival (OS) and cause-specific survival (CSS) risk with corresponding 95% confidence intervals (CIs). Results: Of 3641 mEOGC patients, 442 (12.1%) received palliative gastrectomy. After PSM, 596 patients were included in the analysis, with 298 in each group. For the matched cohort, the median survival was 8 months, and the 5-year survival was 4.0%. The median OS of mEOGC patients undergoing palliative gastrectomy was significantly longer than that of patients without surgery (13 months vs. 6 months, p < 0.001), and palliative gastrectomy remained an independent protective factor after adjusting for confounders (HR 0.459, 95% CI 0.382-0.552, p < 0.001), and the protective effect was robust in the subgroup analysis. Similar results were indicated in CSS. Stratified analyses by treatment modality also warranted the superiority of palliative-gastrectomy-based treatment in improving OS and CSS. Conclusions: mEOGC patients with palliative gastrectomy had a significantly longer survival time than patients without surgery. Exploratory analysis confirmed that surgery-based therapy modality was superior in improving survival time.

Emergency exploratory laparotomy and radical gastrectomy in patients with gastric cancer combined with acute upper gastrointestinal bleeding

BACKGROUND

Gastric cancer (GC) is a prevalent malignant tumor worldwide and ranks as the fourth leading cause of cancer-related mortality. Upper gastrointestinal bleeding (UGIB) is a frequent complication of GC. Radical gastrectomy and palliative therapy are widely used surgical procedures in the clinical management of GC. This study intends to probe the clinical efficacy and safety of radical gastrectomy and palliative therapy on the basis of exploratory laparotomy in patients with GC combined with UGIB, hoping to provide valuable information to aid patients in selecting the appropriate surgical intervention.

AIM

To investigate the clinical efficacy and safety of exploratory laparotomy + radical gastrectomy and palliative therapy in patients with GC and UGIB combined.

METHODS

A total of 89 GC patients admitted to the First Affiliated Hospital of the University of South China between July 2018 and July 2020 were selected as participants for this study. The 89 patients were divided into two groups: radical resection group (n = 46) treated with exploratory laparotomy + radical gastrectomy and Palliative group (n = 43) treated with palliative therapy. The study compared several variables between the two groups, including surgical duration, intraoperative blood transfusion volume, postoperative anal exhaust time, off-bed activity time, length of hospitalization, and incidence of complications such as duodenal stump rupture, anastomotic obstruction, and postoperative incision. Additionally, postoperative immune function indicators (including CD3+, CD4+, CD8+, CD4+/CD8+, and CD3+/HLADR+), immunoglobulin (IgG and IgM), tumor markers (CEA, CA199, and CA125), and inflammatory factors (IL-6, IL-17, and TNF-α) were assessed. The surgical efficacy and postoperative quality of life recovery were also evaluated. The patients were monitored for survival and tumor recurrence at 6 mo, 1 year, and 2 years post-surgery.

RESULTS

The results indicated that the duration of operation time and postoperative hospitalization did not differ between the two surgical procedures. However, patients in the radical resection group exhibited shorter intraoperative blood loss, anus exhaust time, off-bed activity time, and inpatient activity time than those in the Palliative group. Although there was no substantial difference in the occurrence of postoperative complications, such as duodenal stump rupture and anastomotic obstruction, between the radical resection group and Palliative group (P > 0.05), the radical resection group exhibited higher postoperative immune function indicators (including CD3+, CD4+, CD8+, etc.) and immunoglobulin levels (IgG, IgM) than the Palliative group, while tumor markers and inflammatory factors levels were lower than those in the radical resection group. Additionally, surgical efficacy, postoperative quality of life, and postoperative survival rates were higher in patients who underwent radical gastrectomy than in those who underwent palliative therapy. Moreover, the probability of postoperative tumor recurrence was lower in the radical gastrectomy group compared to the palliative therapy group, and these differences were all statistically significant (P < 0.05).

CONCLUSION

Compared to palliative therapy, exploratory laparotomy + radical gastrectomy can improve immune function, reduce the levels of tumor markers and inflammatory factors, improve surgical efficacy, promote postoperative quality of life recovery, enhance survival rates, and attenuate the probability of tumor recurrence.

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Impact of gastrectomy for incurable advanced gastric cancer in urgent situations in the elderly

BACKGROUND

Chemotherapy is the standard treatment for incurable advanced gastric cancer; however, its indications are limited in elderly patients. Furthermore, the efficacy of chemotherapy and surgery as well as the treatment strategy for incurable gastric cancer in elderly patients with urgent conditions are unclear. In these situations, palliative gastrectomy or gastrojejunostomy is often performed. Less invasive surgical procedures should be performed on elderly patients in consideration of their condition; however, gastrectomy may be preferable if it can improve the prognosis. Therefore, we investigated the significance of palliative gastrectomy in elderly patients with incurable advanced gastric cancer who underwent surgery due to stenosis or bleeding.

METHODS

Fifty-six patients aged >80 years with stage IV incurable advanced gastric cancer who underwent surgery at our department between February 1992 and July 2021 were included in the study. The patients underwent gastrectomy (distal and total gastrectomy) or gastrojejunostomy. We examined the association between the clinicopathological factors and overall survival after surgery.

RESULTS

The subjects included 43 men and 13 women. Twenty-nine patients underwent distal gastrectomy or total gastrectomy, and 27 underwent gastrojejunostomy. The median follow-up duration for all patients was 297 days. The univariate analysis indicated significant differences in the surgical procedure and blood loss. Multivariate analysis showed a significant difference only in the surgical procedure (hazard ratio, 5.32; 95% confidence interval, 2.43-11.6; P < 0.001).

CONCLUSIONS

Gastrectomy as a palliative surgery for incurable advanced gastric cancer in elderly patients may improve their prognosis.

The Impact of Palliative Radiation Therapy on Patients With Advanced Gastric Cancer: Results of a Retrospective Cohort Study

Aim In advanced gastric cancer, symptoms such as loss of appetite, stomach tightness, occasional pain, vomiting blood, and melena may occur. Palliative radiation therapy may be indicated in such cases. This study aimed to investigate the clinical outcomes of palliative radiotherapy in patients with advanced-stage gastric carcinoma. Methods From April 2018 to October 2022, consecutive patients with non-resected advanced gastric cancer who received radiation therapy for palliation of symptoms were included. Results A total of 23 patients with advanced-stage gastric carcinoma were analyzed in this study. Twelve male and 11 female patients were included. The median overall survival period was 3.9 months (95% confidence interval: 1.0-8.7 months). Sixteen patients required erythrocyte transfusion before radiotherapy; for 13 patients (83%), the required units of erythrocyte transfusion decreased after palliative radiotherapy. The mean erythrocyte transfusion units significantly decreased from 4.2 (standard deviation [SD]: 4.3) to 1.7 (SD: 3.6) (p = 0.02). No adverse events of grade ≥3 were observed in this study population. Conclusion Palliative radiation therapy for advanced gastric cancer yielded a good response rate and can be a useful treatment option.

The Role of Palliative Surgery in Stage IV Gastric Cancer: A Retrospective Study

Background: Palliative chemotherapy is the mainstay of treatment for metastatic gastric adenocarcinoma but in some patients, surgically correctable factors such as obstruction lead to intolerance of further systemic treatment. The aim of this study was to evaluate the role of selective palliative surgery in incurable gastric cancer. Methods: All patients with stage IV and locally advanced unresectable gastric adenocarcinoma treated at a single centre from March 2006 to January 2019 were included. Data were retrieved from a prospectively maintained database. Patients were categorized into palliative surgery (PS) and no surgery (NS). Results: Of 666 patients with gastric cancer treated over the study period, 146 patients had stage IV gastric adenocarcinoma and 121 patients met inclusion criteria. Sites of metastases were peritoneum (55; 46%), non-regional lymph nodes (10; 8%), solid organ (17, 14%), adjacent organ invasion (4, 3.3%) and a combination of factors (32, 26%). Forty-six (38%) patients underwent palliative surgery which included anatomical gastrectomy (total, subtotal, distal or proximal, 78%) gastro-jejunal bypass and feeding jejunostomy (12%). Thirty-day post-operative complications occurred in 24 patients (52%) with one mortality (2.1%). Following surgery, 52% received systemic chemotherapy. For the PS and NS groups respectively, median overall survival was 9.1 versus 9.4 months (p = 0.6) and median progression-free survival was 7.1 versus 6.7 months (p = 0.2) after a follow up period of 7.3 (4.7-13.1) versus 7.8 (2.6-13.4) months (p = 0.46). Conclusion: Targeted surgical intervention for incurable gastric cancer can be used to palliate symptoms and facilitate continuation of systemic therapy with acceptable risks and post-operative outcomes.

Palliative gastrectomy for metastatic gastric adenocarcinoma: A national population-based cohort study

BACKGROUND

The impact of palliative gastrectomy for metastatic gastric adenocarcinoma, especially by site of metastasis remains unclear.

METHODS

The National Cancer Database, 2010-2015, was used to identify patients with clinical metastatic (cM1) gastric adenocarcinoma (n = 19,411) at diagnosis. The main variable was index management for cM1 gastric adenocarcinoma (ie, no treatment, palliative chemotherapy, or palliative gastrectomy). Cox multivariable analyses were used to account for treatment selection bias and reported as hazard ratio (HR) and 95% confidence interval.

RESULTS

Of 19,411 patients, 10,893 (56%) received palliative chemotherapy, and only 1,101 (6%) received palliative gastrectomy only. The median survival was 6.1 months, and 5-year survival was 4% in the entire cohort. Patients receiving palliative gastrectomy had a significantly longer survival than patients without any treatment or palliative chemotherapy (median: 12.8 vs 1.8 vs 9.5 months, P < .001), which remained after multivariable adjustment (HR: 0.76, 95% confidence interval: 0.71-0.81, P < .001) compared with palliative chemotherapy. Stratified analyses by clinical nodal stage (cN) demonstrated survival benefit with palliative gastrectomy: cN0 (HR: 0.71, 95% confidence interval: 0.62-0.82), cN1 (HR: 0.68, 95% confidence interval: 0.59-0.79), cN2 (HR: 0.86, 95% confidence interval: 0.70-0.94), and cN3 (HR: 0.82, 95% confidence interval: 0.70-0.92) over palliative chemotherapy. Stratified analyses by metastasis site demonstrated that palliative gastrectomy remained superior compared with palliative chemotherapy for metastatic disease limited to liver, bone, and peritoneum, but equivalent to lung metastasis and inferior to brain metastasis.

CONCLUSION

Palliative gastrectomy appears to have a modest survival benefit over palliative chemotherapy alone. Differences in outcomes by site of metastasis warrant further research to understand tumor biology and identify specific subgroups which may benefit from palliative gastrectomy.