The influence of case load and the extent of resection on the quality of treatment outcome in gastric cancer

Harnessing interventions during the immediate perioperative period to improve the long-term survival of patients following radical gastrectomy

Although the incidence and mortality of gastric cancer (GC) have been decreasing steadily worldwide, especially in East Asia, the disease burden of this malignancy is still very heavy. Except for tremendous progress in the management of GC by multidisciplinary treatment, surgical excision of the primary tumor is still the cornerstone intervention in the curative-intent treatment of GC. During the relatively short perioperative period, patients undergoing radical gastrectomy will suffer from at least part of the following perioperative events: Surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response, which have been shown to affect long-term outcomes. Therefore, in recent years, studies have been carried out to find and test interventions during the perioperative period to improve the long-term survival of patients following radical gastrectomy, which will be the aim of this review.

[Minimum case volume regulations in surgery from the perspective of the specialist society (DGCH) : Balancing act between science, politics, treatment reality and a range of other aspects]

Die wissenschaftlich begründete, fachchirurgische Diskussion um die gesetzliche Vorgabe von Mindesteingriffszahlen für diverse Organsysteme und ausgewählte operative Maßnahmen als Basis einer Qualitätssicherung und Versorgungsoptimierung ist nicht neu. Hierzu liegen umfangreiche und auch belastbare Daten aus nationalen und internationalen Studien für die kolorektale Chirurgie, die Pankreaschirurgie, die Ösophaguschirurgie, die Leberchirurgie und die Magenchirurgie vor. Jüngst hat die Anhebung der Mindestmenge für komplexe Eingriffe am Ösophagus durch den Gemeinsamen Bundesausschuss (G-BA) von 10 auf 26 pro Klinik und Jahr die Debatte um dieses Thema, aber auch die Debatte über die Zentralisierung im Gesundheitswesen im Generellen neu aufgerollt. Die Anhebung erscheint aus Sicht der politischen Gremien wissenschaftlich gut begründet und in der praktischen Umsetzung realisierbar. Aus Sicht der tagtäglich mit den entsprechenden hochkomplexen Entitäten vertrauten Ärzten ergibt sich allerdings eine sehr viel breitere Diskussionsgrundlage, welche nur partiell durch ein Gutachten des Instituts für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) als Grundlage des G‑BA-Beschlusses abgedeckt wird. Für die wissenschaftlich orientierte chirurgische Fachgesellschaft steht dabei in erster Linie die wissenschaftliche Evidenz als Handlungsmaxime im Vordergrund. Gleichwohl können und dürfen Aspekte der Versorgungsrealität nicht ausgeblendet werden. Die Empfehlungen der Fachgesellschaft müssen sich somit neben der Ergebnisqualität auch an der praktischen Realisierbarkeit orientieren. Darüber hinaus sind Fragen der Weiterbildung, das Recht des Patienten auf freie Arztwahl sowie auch der Erhalt der Attraktivität des Berufsbildes Chirurg immanente Themen der chirurgischen Fachgesellschaft.

Analysis of postoperative morbidity and mortality following surgery for gastric cancer. Surgeon volume as the most significant prognostic factor

Introduction

Surgical resection is the only potentially curative modality for gastric cancer and it is associated with substantial morbidity and mortality.

Aim

To determine risk factors for postoperative morbidity and mortality following major surgery for gastric cancer.

Material and methods

Between 1.08.2006 and 30.11.2014 in the Department of Oncological Surgery of Gdynia Oncology Centre 162 patients underwent gastric resection for adenocarcinoma. All procedures were performed by 13 surgeons. Five of them performed at least two gastrectomies per year (n = 106). The remaining 56 resections were done by eight surgeons with annual volume lower than two. Perioperative mortality was defined as every in-hospital death and death within 30 days after surgery. Causes of perioperative deaths were the matter of in-depth analysis.

Results

Overall morbidity was 23.5%, including 4.3% rate of proximal anastomosis leak. Mortality rate was 4.3%. Morbidity and mortality were not dependent on: age, gender, body mass index, tumour location, extent of surgery, splenectomy performance, or pTNM stage. The rates of morbidity (50% vs. 21.3%) and mortality (16.7% vs. 3.3%) were significantly higher in cases of tumour infiltration to adjacent organs (pT4b). Perioperative morbidity and mortality were 37.5% and 8.9% for surgeons performing less than two gastrectomies per year and 16% and 0.9% for surgeons performing more than two resections annually. The differences were statistically significant (p = 0.002, p = 0.003).

Conclusions

Annual surgeon case load and adjacent organ infiltration (pT4b) were significant risk factors for morbidity and mortality following major surgery for gastric cancer. The most common complications leading to perioperative death were cardiac failure and proximal anastomosis leak.

Report from the 17th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Edmonton, Alberta; 11-12 September 2015

The 17th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Edmonton, Alberta, 11-12 September 2015. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of gastric cancer.

Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy

BACKGROUND

Gastric cardia cancer is currently treated with several operations. The purpose of the current study was to compare outcomes associated with three common operative approaches.

METHODS

The ACS-NSQIP Participant Use File was searched to identify all patients with gastric cardia malignancy who underwent total gastrectomy (TG), transhiatal esophagectomy (THE), or thoraco-abdominal esophagectomy (TAE) between 2005 and 2012. Demographic, perioperative risk factors, and outcomes were analyzed.

RESULTS

Overall, there were 982 patients identified in the database who met inclusion criteria. The median age was 65 years (range 20-88) and 807 (82.2%) were male. The number of patients allocated to each approach was 204 TGs (20.8%), 271 THE (27.6%), and 507 TAE (51.6%). All approaches had similar major morbidity, cardiopulmonary morbidity, and 30-day mortality, however, TAE was associated with the highest overall morbidity (TAE 49.9% vs. TG 40.7% and THE 43.5%, p = 0.048). The independent risk factors predicting mortality were age greater than 65 years, history of myocardial infarction, and postoperative cardiopulmonary morbidity.

CONCLUSIONS

For patients with proximal gastric cancer, the three most common operative approaches were associated with clinically-significant rates of overall and major morbidity. Approach-associated morbidity should be considered along with tumor location and extent when choosing a technique for resection of gastric cardia malignancy.

Hospital Readmission Following Surgery for Gastric Cancer: Frequency, Timing, Etiologies, and Survival

BACKGROUND

Readmission rates after cancer surgery are infrequently reported, and better understanding of the etiologies for readmission is necessary. We sought to investigate the frequency, timing, and etiologies for hospital readmission after surgery for gastric cancer and whether readmission correlates with clinical outcomes.

STUDY DESIGN

Hospital readmission was examined through linkage of the California Cancer Registry with the Office of Statewide Health Planning and Development database. Patients with gastric adenocarcinoma who had undergone curative intent surgery between 2000 and 2011 were identified. First readmission within 90 days of initial surgery was analyzed with respect to timing (0-30, 31-60, and 61-90 days) and etiology for readmission. Variables associated with readmission and impact on 5-year overall survival (OS) were examined.

RESULTS

A total of 8887 (male, n = 5326; female, n = 3561) patients underwent curative intent surgery for gastric adenocarcinoma. Within 90 days of initial surgery, 2559 (28.8 %) patients had inpatient hospital readmission. The majority of readmissions occurred in the first 30 days [0-30, n = 1371 (53.6 %); 31-60, n = 773 (30.2 %); and 61-90, n = 415 (16.2 %)]. Readmission vs. no readmission within 90 days correlated with worse 5-year OS in patients with local (51.2 vs. 70.9 %, p < 0.0001) and regional (23.3 vs. 32.9 %, p < 0.0001) disease. On multivariate analysis, readmission within 90 days was associated with worse OS (HR 1.40, 95 % CI 1.32-1.49, p < 0.001).

CONCLUSIONS

Hospital readmissions are high after surgery for gastric cancer and correlate with poor patient survival. A better understanding of these issues may allow health care providers to potentially lower readmission rates and improve gastric cancer outcomes.

Is England closing the international gap in cancer survival?

BACKGROUND

We provide an up-to-date international comparison of cancer survival, assessing whether England is 'closing the gap' compared with other high-income countries.

METHODS

Net survival was estimated using national, population-based, cancer registrations for 1.9 million patients diagnosed with a cancer of the stomach, colon, rectum, lung, breast (women) or ovary in England during 1995-2012. Trends during 1995-2009 were compared with estimates for Australia, Canada, Denmark, Norway and Sweden. Clinicians were interviewed to help interpret trends.

RESULTS

Survival from all cancers remained lower in England than in Australia, Canada, Norway and Sweden by 2005-2009. For some cancers, survival improved more in England than in other countries between 1995-1999 and 2005-2009; for example, 1-year survival from stomach, rectal, lung, breast and ovarian cancers improved more than in Australia and Canada. There has been acceleration in lung cancer survival improvement in England recently, with average annual improvement in 1-year survival rising to 2% during 2010-2012. Survival improved more in Denmark than in England for rectal and lung cancers between 1995-1999 and 2005-2009.

CONCLUSIONS

Survival has increased in England since the mid-1990s in the context of strategic reform in cancer control, however, survival remains lower than in comparable developed countries and continued investment is needed to close the international survival gap.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and five-year survival rates are poor, therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately, in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-, intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index (e.g., Charlson comorbidity index), assessment of nutritional status (e.g., short nutritional assessment questionnaire, nutritional risk screening - 2002) and frailty assessment (Groningen frailty indicator, Edmonton frail scale, Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential. Implementation of fast-track or enhanced recovery after surgery programs is showing promising results, although future studies have to determine what the exact optimal strategy is. Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection. Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far. Advances in postoperative care include optimal timing of oral diet, which has been shown to reduce hospital stay. In general, hospital volume, i.e., centralization, and clinical audits might further improve the outcome in gastric cancer surgery. In conclusion, progress has been made in improving the surgical treatment of gastric cancer. However, gastric cancer treatment is high risk surgery and many areas for future research remain.

Value of geriatric frailty and nutritional status assessment in predicting postoperative mortality in gastric cancer surgery

OBJECTIVES

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

METHODS

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

RESULTS

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3%. Patients with a GFI ≥ 3 (n = 30, 24%) had a mortality rate of 23.3% versus 5.2% in the lower GFI group (OR 4.0, 95%CI 1.1-14.1, P = 0.03). For patients who underwent surgery with curative intent (n = 125), this was 27.3% for patients with GFI ≥ 3 (n = 22, 18%) versus 5.7% with GFI < 3 (OR 4.6, 95% CI 1.0-20.9, P = 0.05). SNAQ ≥ 1 (n = 98, 61%) was associated with a mortality rate of 13.3% versus 3.2% in patients with SNAQ =0 (OR 5.1, 95% CI 1.1-23.8, P = 0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

CONCLUSIONS

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.

[Surgical treatment of gastric carcinoma. German multicenter observational studies]

The aim of the review is to compare the results of selected German multicenter observational studies on the surgical treatment of gastric carcinoma within the last two decades. Overall, 6,035 patients with gastric cancer who had been registered in numerous German comprehensive surgical clinics and departments in the time periods 1986-1989, January through December 2002 and 2007-2009 were enrolled in this analysis. In particular, the study aimed to investigate the most important criteria and factors with an impact on the perioperative and early postoperative outcome including the effects on oncological long-term results. In addition to the advances in diagnostic procedures and surgical techniques, the impact of multimodal therapeutic concepts which have been established particularly in the third investigation period is emphasized.

[Current S3 guidelines on surgical treatment of gastric carcinoma]

The current S3 guidelines on the diagnosis and treatment of gastric carcinoma including those of the esophagogastric junction describe optimal clinical practice based on a high level of evidence and expert consensus from different medical disciplines. Endoscopy and performance of multiple biopsies is the standard approach to detect malignant tumors in the upper gastrointestinal tract. Further diagnostic procedures are necessary to evaluate the tumor stage. With the exception of mucosal carcinomas, surgical therapy is the cornerstone of curative treatment in all potentially resectable stages. In locally advanced carcinomas perioperative chemotherapy should be carried out and in high-seated tumors preoperative radiochemotherapy might be an alternative option. Palliative surgical resection should be avoided in disseminated asymptomatic stages. In a palliative situation complications of the tumor should primarily be treated by interventional or conservative procedures.

[Surgery of gastric cancer in a medium volume center]

BACKGROUND

The aim of the study was to evaluate prognostic factors for the surgical treatment of gastric cancer in a medium volume center. The investigation focused in particular on morbidity and mortality.

PATIENTS AND METHODS

From January 2005 to August 2011 a total of 74 patients with gastric cancer were surgically treated in our medium volume center. The study of these patients included morbidity, mortality, UICC (International Union Against Cancer) stage, Laurén classification, surgical therapy procedure, American Society of Anesthesiologists (ASA) classification and duration of surgery.

RESULTS

After surgery 11 patients suffered from complications with a morbidity of 14.9% and a mortality of 1.4% (n=1). No significant differences could be detected during the study period.

CONCLUSION

In comparison to other studies the morbidity and mortality rates signify similar to better data than complications of high volume centers which might be due to the small group of surgeons who are specialized in gastric surgery.

Treatment strategies in gastric cancer

BACKGROUND

Gastric cancer has become less common but remains among the leading causes of death from cancer, with a 5-year survival rate of only 20% to 25%. Although diagnostic techniques have improved, most patients with gastric cancer in the Western world (unlike in some Asian countries) already have locally advanced disease when diagnosed and may thus need not only surgery, but also perioperative chemotherapy and/or radiotherapy.

METHOD

Articles published from 2000 to 2010 and containing the terms "gastric cancer," "surgery," and "chemotherapy" in combination with "review" or "randomized trial" were retrieved by a search in the Cochrane Library and Medline databases and selectively reviewed.

RESULTS

Complete (R0) resection of the tumor remains the standard treatment whenever possible. Complete endoscopic resection suffices only in special types of carcinoma that are confined to the gastric mucosa. Depending on the histological findings, either a subtotal distal gastrectomy or a total (perhaps extended total) gastrectomy can be performed. The long-term benefit of systematic D2 lymphadenectomy has now been shown in a randomized trial: the rates of tumor-related death and of local or regional recurrence were found to be significantly lower with D2 than with D1 lymphadenectomy. Multimodal treatment strategies including perioperative chemotherapy and/or radiotherapy can further improve local and regional tumor control and lessen the rate of systemic metastasis.

CONCLUSION

The standardization of surgical procedures lowered the operative risk in the treatment of gastric cancer. Patients with locally advanced disease can now derive additional benefit from perioperative chemotherapy with an increase of the 5-year survival rates of more than 10%.

Enforcing centralization for gastric cancer in Denmark

BACKGROUND

Population-based data on the early postoperative outcome after surgery for gastric cancer are very sparse. We examined the development in the quality of surgery and early postoperative outcomes in Denmark following centralization of gastric cancer surgery and implementation of national clinical guidelines.

METHODS

All patients in Denmark who underwent resection with curative intent for gastric cancer between 1st July 2003 and 31st December 2008 in one of five university hospitals were registered in a national database. Data on surgical quality and mortality were obtained from the database and compared with the results from the period before centralization (1999-2003).

RESULTS

A total of 416 patients underwent resection in the study period. The risk of anastomotic leakages for the whole period was 5.0% (95%CI; 3.2-7.7) compared to 6.1% (95%CI; 4.3-8.6) before centralization, whereas the 30-days hospital mortality was 2.4% (95%CI; 1.2-4.4) compared to 8.2% (95%CI; 6.0-10.4) before centralization. In addition, the percentage of patients with at least 15 lymph nodes removed increased during the study period from 19 in 2003 to 76 in 2008.

CONCLUSIONS

Centralization of gastric cancer surgery in Denmark and implementation of national clinical guidelines monitored by a national database was associated with improvements in surgical quality and substantially lower in-hospital mortality.

Optimal surgery for advanced gastric cancer

Locoregional control remains a major problem after surgery, although a curative resection is still the only treatment to offer a cure for patients with gastric cancer. Despite the results of major randomized trials, the extent of nodal dissection continues to be debated. If there is a survival benefit to be gained by extended lymphadenectomy, added operative mortality should be eliminated. A pancreas and spleen-preserving D2 lymphadenectomy provides superior staging information and may provide a survival benefit while avoiding its excess morbidity. Splenectomy during gastric resection for tumors not adjacent to or invading the spleen increases morbidity and mortality without improving survival. Therefore, splenectomy should not be performed unless there is direct tumor extension. The Maruyama Index and nomograms that predict disease-specific survival may help to discriminate between patients with a high risk of relapse and select those patients who will be most likely to benefit from tailored multimodality treatment. There is growing evidence that gastric cancer surgery should be performed in high-volume centers with experienced specialists to reduce morbidity and operative mortality and to achieve better survival results.

Gastric cancer

Gastric cancer is the second most frequent cause of cancer death worldwide, although much geographical variation in incidence exists. Prevention and personalised treatment are regarded as the best options to reduce gastric cancer mortality rates. Prevention strategies should be based on specific risk profiles, including Helicobacter pylori genotype, host gene polymorphisms, presence of precursor lesions, and environmental factors. Although adequate surgery remains the cornerstone of gastric cancer treatment, this single modality treatment seems to have reached its maximum achievable effect for local control and survival. Minimally invasive techniques can be used for treatment of early gastric cancers. Achievement of locoregional control for advanced disease remains very difficult. Extended resections that are standard practice in some Asian countries have not been shown to be as effective in other developed countries. We present an update of the incidence, causes, pathology, and treatment of gastric cancer, consisting of surgery, new strategies with neoadjuvant and adjuvant chemotherapy or radiotherapy, or both, novel treatment strategies using gene signatures, and the effect of caseload on patient outcomes.

Gastric cancer

Gastric cancer is the second most frequent cause of cancer death worldwide, although much geographical variation in incidence exists. Prevention and personalised treatment are regarded as the best options to reduce gastric cancer mortality rates. Prevention strategies should be based on specific risk profiles, including Helicobacter pylori genotype, host gene polymorphisms, presence of precursor lesions, and environmental factors. Although adequate surgery remains the cornerstone of gastric cancer treatment, this single modality treatment seems to have reached its maximum achievable effect for local control and survival. Minimally invasive techniques can be used for treatment of early gastric cancers. Achievement of locoregional control for advanced disease remains very difficult. Extended resections that are standard practice in some Asian countries have not been shown to be as effective in other developed countries. We present an update of the incidence, causes, pathology, and treatment of gastric cancer, consisting of surgery, new strategies with neoadjuvant and adjuvant chemotherapy or radiotherapy, or both, novel treatment strategies using gene signatures, and the effect of caseload on patient outcomes.

Improved survival after resectable non-cardia gastric cancer in The Netherlands: the importance of surgical training and quality control

BACKGROUND

In The Netherlands, standardised limited D1 and extended D2 lymph node dissections in the treatment of resectable gastric cancer were introduced nationwide within the framework of the Dutch D1-D2 Gastric Cancer Trial between 1989 and 1993. In a population-based study, we evaluated whether the survival of patients with resectable gastric cancer improved over time on a regional level.

METHODS

We compared 5-year overall and relative survival of patients with curatively resected non-cardia gastric cancer in the regional cancer registry of the Comprehensive Cancer Centre West in The Netherlands before the Dutch D1-D2 trial (1986 to mid 1989; n = 273), during the trial period (mid 1989 to mid 1993; n = 255), and after the trial (mid 1993 to 1999; n = 219), adjusting for prognostic variables.

RESULTS

Unadjusted survival was highest in the post-trial period: 5-year overall and relative survival were 42% and 52%, respectively, compared to 34% and 41% in the pre-trial period, and 39% and 46% in the trial period (p = 0.31 and p = 0.06, respectively). After adjustment for age, gender, tumour site, pT-stage, nodal status and hospital volume, the effect of period on survival was more apparent (p = 0.009). Compared to the pre-trial period, the hazard ratio was 0.83 (95% confidence interval, 0.68-1.02) for the trial period, and 0.72 (0.58-0.89) after the trial. Less than 1% of the patients received adjuvant therapy.

CONCLUSION

Survival of patients with curatively resected non-cardia gastric cancer has improved. Standardisation and surgical training in D1 and D2 lymph node dissection are the most likely explanation for this improvement.

Surgeons' knowledge of quality indicators for gastric cancer surgery

BACKGROUND

Gastric cancer survival in the West is inferior to that achieved in Asian centers. While differences in tumor biology may play a role, poor quality surgery likely contributes to understaging. We hypothesize that the majority of surgeons performing gastric cancer surgery in North America are unaware of the recommended standards.

METHODS

Using the Ontario College of Physicians and Surgeons registry, surgeons who potentially included gastric cancer surgery in their scope of practice were identified. A questionnaire was mailed to 559; of those, 206 surgeons reported managing gastric cancer. Results were evaluated by chi(2) and logistic regression; P < 0.05 was considered significant.

RESULTS

Eighty-six percent of respondents were male and 53% practiced in an urban nonacademic setting. Forty percent reported operating on two to five cases of gastric cancer per year, and 42% on fewer than two cases per year. One-third of surgeons identified 4 cm or less to be the desired gross proximal margin. Half used frozen section to evaluate margin status. Twenty percent of surgeons were unsure of the number of lymph nodes (LN) needed to accurately stage gastric cancer, and the median number reported by the remainder was 10 (range, 0-30). Only 16 of 206 identified both a proximal margin of 5 cm or less and 15 or more LN as desired targets. Those performing more than five gastric resections per year were more likely to report a D2 resection (P = 0.008).

CONCLUSION

The majority of surgeons operating on gastric cancer in Ontario did not identify recommended quality indicators of gastric cancer surgery. A continuing medical education program should be designed to address this knowledge gap to improve the quality of surgery and patient outcomes.

Self-reported experience and outcomes of care among stomach cancer patients at a median follow-up time of 27 months from diagnosis

GOALS OF WORK

We aimed to identify clinical experiences associated with outcomes of care among stomach cancer patients.

MATERIALS AND METHODS

Four hundred thirty-two patients who had a diagnosis of stage I-III stomach cancer from 2001 through 2002 from two hospitals in South Korea responded to a survey questionnaire including sociodemographic and clinical data, information about care experiences, satisfaction with care, and quality of life (QOL).

MAIN RESULTS

Involvement in decision making [adjusted odds ratio (aOR) = 1.81; 95% confidence interval (CI), 1.13 to 2.89] and reflection of patients' opinions in treatment decisions (aOR = 2.54; 95% CI, 1.65 to 3.93) were associated with decision satisfaction. The factors associated with willingness to choose the same treatment over again were involvement in decision making (aOR = 2.37; 95% CI, 1.53 to 3.68) and no treatment toxicity (aOR = 0.50; 95% CI, 0.29 to 0.87). Involvement in decision making, reflection of patients' opinions in treatment decisions, and treatment toxicity were associated with some functioning subscales of QOL (p < 0.05). Regular follow-up, however, was associated with poor social functioning.

CONCLUSIONS

Quality improvement efforts for stomach cancer patients should focus not only on the quality of primary tumor therapy but also on how patients experience their care, such as patient-centered decision making, experience of treatment toxicity, and regular follow-up.

Short and long-term survival from gastric cancer. A population-based study from a county hospital during 25 years

The aim of this study was to evaluate the outcome for gastric cancer patients treated at a medium sized Norwegian hospital. The medical journals of all 356 patients with gastric cancer treated at Levanger Hospital from 1980 to 2004 were retrospectively analysed. Follow-up with regard to survival was complete. The Department of Surgery had treated 277 patients (78%). The resection rate of patients admitted to the Department of Surgery was 56% (154/277), and the total resection rate was 43% (154/356). R0 resection was done in 97 patients (27%), R1 resection in 16 (4%), palliative R2 resection in 41 (12%), other palliative procedures in 59 (17%), and only palliative care was given for 143 (40%) patients. The 30-days postoperative mortality was 2.7% (3/113) after R0 and R1 resections, 4.9% (2/41) after R2 resections, and 24% (14/59) after other palliative procedures. After R0 resections, the estimated overall 5-year survival was 39% (95% C.I. 29-49). After R1 and R2 resections, none survived 5 years and the estimated overall 2-year survival was 12% (95% C.I. 0-27%) and 2% (95% C.I. 0-7%), respectively. Estimated overall 5-year survival was closely related to stage: 91% (95% C.I. 74-100) in stage 1A, 64% (95% C.I. 53-74) in stage 1B, 27% (95% C.I. 10-44) in stage II, 18% (95% C.I. 4-32) in stage IIIA, and none in stages IIIB and IV. Dysphagia, fatigue, weight loss, palpable tumour, ascites and anaemia were related to a bad prognosis. Dyspepsia, vomiting and hematemesis were not related to the prognosis. Symptoms duration > 6 months were related to a better prognosis than short duration of symptoms < 2 months. The results from this hospital are in accordance with previous reports from the Western world.

Determinants of complications and adequacy of surgical resection in laparoscopic versus open total gastrectomy for adenocarcinoma

BACKGROUND

The role of laparoscopic total gastrectomy (LTG) in the treatment of gastric cancer is controversial. The present study analyzed the morbidity and adequacy of resection in LTG versus open total gastrectomy (OTG) for gastric adenocarcinoma.

METHODS

Between 2003 and 2006, clinical data of 38 consecutive patients who underwent LTG for gastric adenocarcinoma were collected prospectively. The same data-entry form was used for retrospective data collection from 22 consecutive patients who underwent OTG within the same time period. Logistic regression models were used in univariate and multivariate analyses to identify the optimally combined factors related to the occurrence of postoperative complications and to the number of harvested lymph nodes.

RESULTS

Postoperative complications occurred in 24 patients with subsequent mortality in two. Median (range) length of hospital stay was 11 (6-73) days and comparable after LTG versus OTG (p = 0.847). The occurrence of postoperative complications was related (p = 0.004) to the first year of surgery and patients' medical condition before surgery [American Society of Anaesthesiologists (ASA) physical status III]. Microscopic tumor-free margins were obtained in all but two patients. The number of harvested lymph nodes was 17 (0-90), and determined by tumor wall penetration (p = 0.001).

CONCLUSIONS

The occurrence of complications after total gastrectomy is determined by the patients' medical condition before surgery and the surgical expertise, but not by the approach. LTG and OTG can result in adequate tumor-free resection margins and lymph node yield, which is related to the tumor wall penetration. The role of LTG in gastric cancer needs further evaluation in randomized controlled trials with large patient series.

Gastric carcinoma: review of the results of treatment in a community teaching hospital

BACKGROUND

The aim of this study is to provide data on long term results of gastric cancer surgery and in particular the D1 gastric resection.

METHODS

In the period 1992-2004, 235 male and female patients with a median age of 69 and 70 years respectively, were included with a stage I through IV gastric carcinoma, of which 37% was stage IV disease. Whenever possible a gastric resection was performed. In case of obstructive tumour growth palliation was provided by means of a gastro-enterostomy.

RESULTS

Gastrectomy with curative intent was achieved in 50%, palliative resection in 22%, palliative surgery (gastro-enterostomy) in 10% and in 18% irresectability led to surgical exploration only. Patients in the curative intent group demonstrated a 47% survival after 5 years and up to 34% after 10 years. However metastases where seen in 32% of the patients after gastrectomy with curative intent. After palliative resection one year survival was 57%, whereas 19% survived more than 3 years. Overall postoperative morbidity and mortality rates were 40% and 13% respectively.

CONCLUSION

Long term survival after surgery for gastric cancer is poor and is improved by early detection and radical resection. However, palliative resection showed improved survival compared to gastro-enterostomy alone or no resection at all which may be an effect of adjuvant therapy.

Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer

INTRODUCTION

The purpose of this study is to analyze postoperative morbidity and mortality of patients operated on for gastric cancer in a single institution during the last twenty years, and to define risk factors for complications.

MATERIAL AND METHODS

A retrospective study was carried out on 434 patients who underwent gastrectomy for gastric cancer between January 1983 and December 2002. Analysis of main medical and surgical complications and analysis of morbidity risk factors.

RESULTS

Overall morbidity and mortality rates were 38.4% and 2.7% respectively. The most frequent complications were pneumonia (13%) and intra-abdominal abcesses (12%). The main cause of death was anastomotic dehiscence with abdominal sepsis. The last ten years mortality rate dropped from 4.7% to 0.8%. Risk factors for complications were gender (male, p = 0.01) and resection of spleen (p = 0.02) or pancreas (p = 0.002). A significantly lesser rate of complications was found in patients who had underwent gastrectomy during the previous five years (p = 0.001) or with tumors located in the lower third of the stomach (p = 0,01).

CONCLUSION

Morbidity of gastrectomy for gastric cancer in our institution is still high but mortality has decreased significantly over the last ten years due to the specialization of the hospital and the surgical team. The main risk factor for complications was pancreatosplenectomy in the multivariate analysis.