Feasibility of radical gastrectomy for elderly patients with gastric cancer

A predictive model for intraabdominal infection after radical gastrectomy in elderly patients

Gastric cancer (GC) is one of the most common malignant tumors worldwide and the fourth leading cause of cancer-related deaths, with a relatively high incidence among the elderly population. Surgical resection is the mainstay treatment for GC and is currently the only cure. However, the incidence of postoperative intraabdominal infections remains high and seriously affects the prognosis. This study aimed to explore the risk factors for intraabdominal infections after radical gastrectomy in elderly patients and to establish and validate a risk prediction model. We collected the clinical data of 322 GC patients, who underwent radical gastrectomy at the General Surgery Department of China Medical University Dandong Central Hospital from January 2016 to January 2023. The patients were divided into an infected group (n = 27) and a noninfected group (n = 295) according to whether intraabdominal infections occurred postoperatively. A nomogram risk prediction model for the occurrence of postoperative intraabdominal infections was developed. All patients were randomized into a training set (n = 225) and a validation set (n = 97) in a 7:3 ratio, and the model was internally validated. Of the 322 patients, 27 (8.3%) experienced postoperative intraabdominal infections. Single-factor analysis revealed associations of intraabdominal infection with body mass index, glucose, hemoglobin, albumin, and other factors. The multifactorial analysis confirmed that body mass index, glucose, hemoglobin, albumin, surgical duration, and bleeding volume were independent risk factors for intraabdominal infections. The nomogram constructed based on these factors demonstrated excellent performance in both the training and validation sets. A nomogram model was developed and validated to predict the risk of intraabdominal infection after radical gastrectomy. The model has a good predictive performance, which could help clinicians prevent the occurrence of intraabdominal infections after radical gastrectomy in elderly patients.

The Impact of Age on the Post-operative Outcomes in Patients Undergoing Resection for Oesophageal and Gastric Cancer

BACKGROUND

Within our ageing population, there is an increasing number of elderly patients presenting with oesophagogastric cancer. Resection remains the mainstay of curative treatment however it has substantial morbidity. The aim of this study was to assess whether age was an independent predictor of resection related complications in our unit.

METHODS

A retrospective cohort study of prospectively collated data from 2002 to 2020 of patients undergoing resection for oesophageal and gastric cancers was analysed. Patients aged over 75 and 75 and under were compared for peri-operative morbidity (via the Clavien-Dindo classification), length of stay (LOS), unplanned readmission, 30- and 90-day mortality, and use of neoadjuvant therapy.

RESULTS

Data for 466 consecutive patients undergoing oesophagogastric resection (277 oesophagectomy and 189 gastrectomy) were available for analysis. 22% of patients were aged over 75 (14% (39/277) of the oesophagectomy cohort, 34% (65/189) of the gastrectomy cohort). Oesophagectomy patients over 75 were more likely to develop post-operative complications, particularly cardiac or thromboembolic, (69.2%) than those in the younger cohort (50.4%, p = 0.029). There was no difference in complication rates between the younger and older patients undergoing gastrectomy (29.0% vs. 33.9% p = 0.495). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.5% (n = 7), respectively, for the oesophagectomy cohort and 1.1% (n = 2) and 1.6% (n = 3) for the gastrectomy cohort, with no difference between age groups.

CONCLUSION

In this series, we found that patients over the age of 75 were able to undergo oesophageal and gastric resection with curative intent with acceptable post-operative morbidity and mortality.

Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis

This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.

Impact of sarcopenia on postoperative pulmonary complications after gastric cancer surgery: A retrospective cohort study

Background

Few studies have investigated the relationship between sarcopenia and postoperative pulmonary complications (PPCs) after gastric cancer surgery. This study aimed to explore the impact of sarcopenia on PPCs in patients who had undergone gastric cancer surgery.

Methods

We included patients who underwent a transabdominal radical gastrectomy between June 2016 and October 2020. Patients were divided into two groups according to the median prevalence rate of lumbar triplane skeletal muscle index (L3 SMI): sarcopenia group (≤37.5% percentile in male and female group) and non-sarcopenia group (>37.5% percentile in male and female group). Baseline characteristics, intraoperative and postoperative conditions, pulmonary complications, and overall complications were compared between the two groups. The primary outcome was the incidence of PPCs. The secondary outcomes were overall postoperative complications and length of stay (LOS).

Results

Among the 143 patients included, 50 had sarcopenia and 93 had not. Compared to the non-sarcopenia group, the sarcopenia group had a higher the incidence of PPCs (22.0% vs. 8.6%, P = 0.024). The incidence of overall postoperative complications in the sarcopenia group was higher than that in the non-sarcopenia group (36.00% vs. 20.43%, P = 0.043). There was no significant difference in the LOS between the two groups.

Conclusions

Our research indicates that sarcopenia, preoperative comorbidities, and longer duration of intraoperative oxygen saturation <95% were risk factors for PPCs. Sarcopenia is an independent risk factor for postoperative complications. Given that our results provided a correlation rather than causation, future prospective randomized trials are needed to confirm the relationship between sarcopenia and prognosis.

Impact of metabolic syndrome on the short- and long-term outcomes for the elderly patients with gastric cancer after radical gastrectomy

BACKGROUND

Metabolic syndrome (MetS) and gastric cancer are age-related diseases, and their incidence rates have risen in past decades. However, few studies have examined the relationship between MetS and the prognosis of elderly patients who underwent radical gastrectomy, and the conclusions remain controversial.

METHODS

We conducted a prospective study of elderly patients who underwent radical gastrectomy for gastric cancer from August 2014 to February 2018. MetS was defined based on visceral fat area (VFA) instead of BMI or waist circumference. Receiver operating characteristic curve analysis was used to determine the cutoff values for VFA.

RESULTS

A total of 585 patients were included in this study. The optimal cutoff values for VFA were 96.1 cm² for men and 105.2 cm² for women, and 212 patients were diagnosed with MetS. The patients with MetS suffered significantly more postoperative complications than those without MetS (37.3% versus 21.4%, P < 0.001). The multivariable logistic regression analysis demonstrated that MetS (OR 2.923, P < 0.001), BMI < 18.5 kg/m² (OR 2.086, P = 0.045), cardiac tumor (OR 1.865, P = 0.013), and Nutritional Risk Screening 2002 scores ≥ 3 (OR 1.654, P = 0.015) were independent risk factors for postoperative complications. During a median follow-up period of 56.4 months, the MetS group and the non-MetS group had comparable overall survival and disease-specific survival.

CONCLUSIONS

MetS was an independent risk factor for complications of the elderly patients after radical gastrectomy, but had no influence on long-term survival.

Developing and validating nomograms for predicting the survival in patients with clinical local-advanced gastric cancer

Background

Many patients with gastric cancer are at a locally advanced stage during initial diagnosis. TNM staging is inaccurate in predicting survival. This study aims to develop two more accurate survival prediction models for patients with locally advanced gastric cancer (LAGC) and guide clinical decision-making.

Methods

We recruited 2794 patients diagnosed with LAGC (2010–2015) from the Surveillance, Epidemiology, and End Results (SEER) database and performed external validation using data from 115 patients with LAGC at Yantai Affiliated Hospital of Binzhou Medical University. Univariate and multifactorial survival analyses were screened for meaningful independent prognostic factors and were used to build survival prediction models. Concordance index (C-index), receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) were evaluated for nomograms. Finally, the differences and relationships of survival and prognosis between the three different risk groups were described using the Kaplan–Meier method.

Results

Cox proportional risk regression model analysis identified independent prognostic factors for patients with LAGC, and variables associated with overall survival (OS) included age, race, marital status, T-stage, N-stage, grade, histologic type, surgery, and chemotherapy. Variables associated with cancer-specific survival (CSS) included age, race, T-stage, N-stage, grade, histological type, surgery, and chemotherapy. In the training cohort, C-index of nomogram for predicting OS was 0.722 (95% confidence interval [95% CI]: 0.708–0.736] and CSS was 0.728 (95% CI: 0.713–0.743). In the external validation cohort, C-index of nomogram for predicted OS was 0.728 (95% CI:0.672–0.784) and CSS was 0.727 (95% CI:0.668–0.786). The calibration curves showed good concordance between the predicted and actual results. C-index, ROC, and DCA results indicated that our nomograms could more accurately predict OS and CSS than TNM staging and had a higher clinical benefit. Finally, to facilitate clinical use, we set up two web servers based on nomograms.

Conclusion

The nomograms established in this study have better risk assessment ability than the clinical staging system, which can help clinicians predict the individual survival of LAGC patients more accurately and thus develop appropriate treatment strategies.

Prediction of Postoperative Survival in Young Colorectal Cancer Patients: A Cohort Study Based on the SEER Database

Objective

Our aim is to make accurate and robust predictions of the risk of postoperative death in young colorectal cancer patients (18-44 years old) by combining tumor characteristics with medical and demographic information about the patient.

Materials and Methods

We used the SEER database to retrieve young patients diagnosed with colorectal cancer who had undergone surgery between 2010 and 2015 as the study cohort. After excluding cases with missing information, the study cohort was divided in a 7 : 3 ratio into a training dataset and a validation dataset. To assess the predictive ability of each predictor on the prognosis of colorectal cancer patients, we used two steps of Cox univariate analysis and Cox stepwise regression to screen variables, and the screened variables were included in a multifactorial Cox proportional risk regression model for modeling. The performance of the model was tested using calibration curves, decision curves, and area under the curve (AUC) for receiver operating characteristic (ROC).

Results

After excluding cases with missing information (n = 23,606), a total of 11,803 patients were included in the study with a median follow-up time of 45 months (1-119). In the training set, we determined that ethnicity, marital status, insurance status, median annual household income, degree of tumor differentiation, type of pathology, degree of infiltration, and tumor location had independent effects on prognosis. In the training dataset, taking 1 year, 3 years, and 5 years as the time nodes, the areas under the working characteristic curve of subjects are 0.825, 0.851, and 0.839, respectively, and in the validation dataset, they are 0.834, 0.837, and 0.829, respectively.

Conclusion

We trained and validated a model using a large multicenter cohort of young colorectal cancer patients with stable and excellent performance in both training and validation datasets.

Clinically Interpretable Machine Learning Models for Early Prediction of Mortality in Older Patients with Multiple Organ Dysfunction Syndrome (MODS): An International Multicenter Retrospective Study

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is associated with a high risk of mortality among older patients. Current severity scores are limited in their ability to assist clinicians with triage and management decisions. We aim to develop mortality prediction models for older patients with MODS admitted to the ICU.

METHODS

The study analyzed older patients from 197 hospitals in the US and one hospital in the Netherlands. The cohort was divided into the young-old (65-80 years) and old-old (≥80 years), which were separately used to develop and evaluate models including internal, external and temporal validation. Demographic characteristics, comorbidities, vital signs, laboratory measurements, and treatments were used as predictors. We used the XGBoost algorithm to train models, and the SHAP method to interpret predictions.

RESULTS

34,497 young-old (11.3% mortality) and 21,330 old-old (15.7% mortality) patients were analyzed. Discrimination AUROC of internal validation models in 9,046 U.S. patients was as follows: 0.87 and 0.82, respectively; Discrimination of external validation models in 1,905 EUR patients was as follows: 0.86 and 0.85, respectively; and of temporal validation models in 8,690 U.S. patients: 0.85 and 0.78, respectively. These models outperformed standard clinical scores like SOFA and APSIII. The GCS, Charlson Comorbidity Index, and Code Status emerged as top predictors of mortality.

CONCLUSIONS

Our models integrate data spanning physiologic and geriatric-relevant variables that outperform existing scores used in older adults with MODS, which represents a proof of concept of how machine learning can streamline data analysis for busy ICU clinicians to potentially optimize prognostication and decision making.

Gastric cancer in older adult patients: a retrospective study and literature review

Background

With increasing life expectancy, the incidence of gastric cancer (GC) in older adults is increasing. This study analyzed differences in GC characteristics according to age and sex among patients who underwent surgical treatment for GC.

Methods

A total of 2,983 patients diagnosed with gastric adenocarcinoma who underwent surgical treatment at Seoul National University Bundang Hospital between 2003 and 2017 were classified into three groups: I (<65 years, n=1,680), II (60–74 years, n=919), and III (≥75 years, n=384). We compared the baseline clinical characteristics, pathological characteristics of the tumor, overall and GC-specific survival rates, and associated risk factors between the groups.

Results

Cancer of the distal third of the stomach (p<0.001), with intestinal-type histology (p<0.001), and with p53 overexpression (p=0.004) were more common in groups II and III than in group I, and the proportion of intestinal-type GC increased with age. The cancer type, lymph node metastasis, and cancer stage did not differ significantly. In terms of overall survival, survival decreased with increasing age (p<0.001), but this difference decreased significantly for GC-specific survival. Cox multivariate analyses revealed age, histologic type (diffuse or mixed type), and advanced cancer stage (p=0.002, 0.001, and <0.001, respectively) as risk factors for GC-related mortality.

Conclusion

Age itself was found to be one of the most important prognostic factors for overall and disease-specific survival in elderly GC patients, along with cancer stage.

The outcome of young vs. old gastric cancer patients following gastrectomy: a propensity score matching analysis

Purpose

The purpose of the current study was to compare the postoperative complications, overall survival and disease-free survival in young and old gastric cancer patients after gastrectomy using propensity score matching (PSM).

Methods

Adult patients (aged ≥ 18 years) who underwent gastrectomy for gastric cancer in a single clinical center from January 2013 to December 2017 were enrolled continuously for retrospective analysis. To minimize the selection bias between the young and old groups, the PSM was conducted in this study.

Results

A total of 558 patients were included in this study, with 51 patients in the young group (aged ≤ 45 years) and 507 patients in the old group (aged > 45 years). After 1:1 matching according to PSM, 51 patients in the young group were matched to 51 patients in the old group. After PSM, there was no difference in the baseline information. In terms of short-term outcomes, no difference was found in operation time (P = 0.190), intraoperative blood loss (P = 0.336), retrieved lymph nodes (P = 0.948), blood transfusion (P = 0.339), postoperative hospital stay (P = 0.194), or postoperative complications (P = 0.477) between the two groups. For overall survival, no statistically significant difference was found in all stages (P = 0.383), stage I (P = 0.431), stage II (P = 0.875) or stage III (P = 0.446) gastric cancer. Furthermore, regarding disease-free survival, no differences were found between the two groups in all stages (P = 0.378), stage I (P = 0.431), stage II (P = 0.879) or stage III (P = 0.510) gastric cancer.

Conclusion

Age might not be an independent prognostic factor for short-term outcomes, OS, or DFS in gastric cancer patients who underwent gastrectomy. The pTNM stage of GC might be an independent prognostic factor for OS and DFS.

Relationship between frailty and mortality after gastrectomy in older patients with gastric cancer

OBJECTIVES

Frail older adults with gastric cancer are at an increased risk of poor postoperative outcomes. We assessed whether geriatric frailty assessed using the Study of Osteoporotic Fractures (SOF) index could predict post-gastrectomy mortality.

MATERIALS AND METHODS

We retrospectively assessed older adults (age ≥ 65 years) who underwent gastrectomy for gastric cancer between April 2012 and September 2015. Frailty status was assessed using the SOF index (range, 0-3) and categorized as robust (0), pre-frail (1), and frail (2-3). The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups. Univariate and multivariate analyses were used to identify mortality-associated risk factors.

RESULTS

Among 231 patients (the median age 72.04 years and 140 (60.6%) men), 138 (59.7%) were robust, 58 (25.1%) were pre-frail, and 35 (15.2%) were frail. The mortality rate was 14.5% among robust patients, 20.7% among pre-frail patients, and 20.0% among frail patients (log-rank test, P = 0.032). Frail patients had more than a 3-fold increased risk of mortality compared with robust patients (adjusted HR = 3.331; 95% CI, 1.161-9.559). Multivariate analysis revealed that the SOF index and TNM stage were associated with increased mortality.

CONCLUSIONS

SOF index predicted post-gastrectomy mortality among older patients independently of age, sex, TNM stage, type of approach, gastrectomy type, and extent of lymph node dissection. SOF index may be used with ease to assess frailty status among older patients with gastric cancer in busy clinics and subgroups that may benefit from targeted frailty interventions before cancer treatments.

Preoperative Prognostic Nutrition Index as a Prognostic Indicator of Survival in Elderly Patients Undergoing Gastric Cancer Surgery

Purpose

Gastric cancer is a common tumor type associated with nutritional and immune status. The aim of the current study was to investigate the prognostic value of a preoperative prognostic nutritional index (PNI), composed of nutritional factors and immune factors in elderly patients undergoing gastric cancer surgery.

Patients and Methods

A total of 454 patients undergoing gastric cancer surgery were divided into two groups based on preoperative PNI scores: ≤45.1 (n = 307) and >45.1 (n = 147). Survival analysis was performed using the Kaplan-Meier method and Log rank tests. Univariate and multivariate analyses were conducted to identify independent prognostic factors using a Cox proportional hazards model.

Results

According to the X-tile program, the optimal cutoff value for predicting overall survival (OS) with the PNI was 45.1. The receiver operating characteristic analysis revealed that PNI exhibited 70.6% sensitivity and 56.5% specificity for predicting death during long-term follow-up. The cumulative incidence of postoperative 4-year mortality indicated that the risk of death increased significantly for PNI ≤45.1. In multivariate analysis, preoperative PNI was a significant independent predictor of mortality. In the age-stratified subgroup analysis, preoperative PNI was more sensitive for the old elderly subgroup than for the young elderly subgroup.

Conclusion

Preoperative PNI is a sensitive and specific prognostic predictor among elderly patients undergoing gastric cancer surgery.

Perioperative outcomes and survival in elderly patients aged ≥ 75 years undergoing gastrectomy for gastric cancer: an 18-year retrospective analysis in a single Western centre

PURPOSE

Surgical resection for elderly patients with gastric cancer is controversial. This study aims to evaluate the preoperative features and postoperative short- and long-term outcomes of elderly patients following surgical resection for gastric adenocarcinoma.

METHODS

Between January 2000 and May 2018, a total of 177 consecutive patients underwent curative gastrectomy for gastric adenocarcinoma was retrospectively reviewed. Propensity score matching (PSM) analysis was used to balance confounding covariates between the elderly and non-elderly groups. Clinicopathological characteristics, intraoperative characteristics, postoperative complications and long-term survival outcomes including overall survival (OS) and Disease Specific Survival (DSS) were compared and analysed using the Kaplan-Meier log-rank test. Multivariate cox proportional hazards regression analysis of clinicopathological factors influencing survival were evaluated.

RESULTS

There were 50 patients in the elderly group (age ≥ 75 years) and 127 patients in the non-elderly group (age < 75 years). Elderly patients had more comorbid conditions (p < 0.001), lower albumin concentration (p = 0.034), lower haemoglobin levels (p = 0.001), and poorer renal function (p = 0.043). TNM stage was similar between both groups (p = 0.174); however, lymphatic invasion (p = 0.006) and lymph node metastasis (p = 0.029) were higher in the elderly group. Elderly patients were much less likely to receive any chemo- (p < 0.001) or radiotherapy treatment (p = 0.007) with surgical treatment. After PSM, there were 50 patients in each group. Elderly patients were more likely to develop complications (Clavien Dindo ≥ 2: 50% vs. 26%, p = 0.003). The most common postoperative complications were pneumonia (12% vs. 6%, p = 0.498) and delirium (10% vs. 0%, p = 0.066). Elderly patients had a longer median length of hospital stay (median (IQR): 15.6(9.5) vs. 11.3 (9.9), p = 0.030). There were no differences in 30-day mortality (elderly vs. non-elderly: 1% vs. 1%, p = 0.988). Before and after PSM, age remains an independent predictor of postoperative complications. Before PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 143 months (95%CI, 123.0-163.8), respectively (p = 0.264). After PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 140 months (95%CI, 112.1-168.2), respectively, (p = 0.360). Before PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 121 months (95%CI, 100.9-141.0), respectively (p = 0.405). After PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 115 months (95%CI, 87.3-143.3), respectively (p = 0.721). Age was not an independent predictor of mortality following gastrectomy for gastric cancer in both PSM matched and unmatched cohort.

CONCLUSION

Chronological age alone is not a contraindication to curative resection of gastric adenocarcinoma in elderly patients with acceptable risk. Whilst age affects perioperative complications, the incidence of postoperative mortality and overall survival were not significantly different between elderly and non-elderly gastric cancer patients treated with curative surgery. Gastrectomy with D2 lymphadenectomy can also be performed in carefully selected elderly patients by surgeons with expertise in gastric resection along with appropriate perioperative management.

The role of surgery in patients aged 85 years or older with resectable gastric cancer: a propensity score matching analysis of the SEER database

Introduction: An increasing number of newly diagnosed resectable gastric cancer (GC) patients are over 85 years of age. However, studies on surgical treatment in these patients are limited. This study aimed to explore the prognosis of a large sample of the oldest old GC patients receiving surgery.Methods: A total of 2914 oldest old patients with stage I-III GC were included in the linked Surveillance, Epidemiology, and End Results (SEER) database from 2006 to 2015. Based on their treatment, we assigned these patients to the surgery and no surgery groups. We used propensity score matching (1:1) to balance the baseline characteristics. The Kaplan-Meier method was used for the survival analysis. Multivariate Cox regression analysis was used to analyse the independent risk factors.Results: After propensity score matching, the median overall survival (OS) times in the surgery and no surgery groups were 24.0 (95% CI: 20.3-27.7) and 4.0 (95% CI: 3.5-4.5) months, respectively (p < .01). Age, sex, stage, histological type, and treatment with surgery and chemotherapy were independent risk factors for OS in the oldest old patients with GC. In total, 19% of the oldest old patients with GC died from causes unrelated to cancer.Conclusions: The current large-scale study demonstrated that the oldest old patients with stage I-III GC could benefit from elective surgery.

A nomogram for predicting cancer-specific survival in different age groups for operable gastric cancer: a population-based study

Background

The age thresholds for differentiating young and elderly patients are still under debate. This study aimed to evaluate the cut-off age for differentiating patients along with the prognostic value of age for operable gastric cancer (GC).

Methods

Patients diagnosed with resected gastric adenocarcinoma were identified from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database (training cohort and internal validation cohort) and Liaoning Cancer Hospital (external validation cohort). Kaplan-Meier plots were used to compare cancer-specific survival (CSS) across different age groups. Univariate and multivariate analysis was conducted using a Cox regression model. Predictive ability of the nomogram was determined by the Harrell’s concordance index (C-index), calibration curves, and Akaike’s Information Criterion (AIC).

Results

A total of 17,339 patients with GC were included. According to the univariate analysis results, CSS was similar among patients aged 20–69 years old, started to worsen for patients over the age of 70, and was the worst for patients older than 79 years in the training cohort. Thus, we further divided the age groups into 20–69, 70–79, and >79, and multivariate analysis showed that patients above 70 years of age had worse CSS. The nomogram was established based on the results of the multivariate analysis. The C-indexes for the training, internal, and external validation cohorts were 0.7531, 0.7344, and 0.7431, respectively.

Conclusions

This study showed that age had a relative predictive ability for CSS, 70 years should be the cut-off age, and age ≥70 years is an independent prognostic risk factor for GC patients who undergo surgery. These data highlight the importance of individualized treatment to improve the prognosis of patients with GC.

Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years

BACKGROUND

The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival.

METHODS

A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied.

RESULTS

A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005).

CONCLUSION

Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

Influence of age on postoperative complications especially pneumonia after gastrectomy for gastric cancer

Background

The aim of this study was to investigate the influence of patients’ age on postoperative morbidities including pneumonia.

Methods

We reviewed the clinical records of 211 patients with stages I – III gastric cancer undergoing curative distal gastrectomy (DG) or total gastrectomy (TG). Patients were classified into an elderly (≧80 y.o.) or a control (< 80 y.o.) group. We compared patient characteristics (sex ratio, disease stage, degree of lymph node dissection, number of retrieved lymph nodes, and type of reconstruction) and early postoperative outcomes (operation time, intra-operative blood loss, and postoperative morbidity including pneumonia, and mortality) between the two groups separately in DG and TG.

Results

There were 134 and 77 patients who underwent DG and TG, respectively. The numbers of patients in the elderly and control groups were 25 and 109 in DG and 12 and 65 in TG. The percentage of female patients in the elderly group was greater than that in the control group in both DG and TG. The extent of lymph node dissection did not differ between two groups in TG; in contrast in DG, the rate of a D1 dissection was greater in the elderly group than in the control group. There were no differences between the two groups in distribution of disease stage, number of retrieved lymph nodes, operation time, and blood loss in DG and in TG. Overall postoperative morbidity did not differ between two groups after DG and after TG. The rate of infectious complications in the elderly group was not different from that in the control group after DG and after TG. The incidence of pneumonia was more frequent in the elderly group compared to the control group after DG (8% vs. 1%, P < 0.05) but not after TG (17% vs. 5%). When patients were compared between the elderly and the control groups regardless of type of gastrectomy, the incidence of pneumonia in the elderly group (4/37 (11%)) was greater than that in the control group (4/174 (2%), P < 0.05).

Conclusions

These results suggest that pneumonia is increased in patients older than 80 years after DG.

Surgical Oncology and Geriatric Patients

Geriatric medicine is a growing field filled with complicated patients who are susceptible to developing cancer. Surgical oncology is expanding while adapting to the increasing elderly population and creating novel treatment regimens for this group of patients. This article reviews surgical oncology in elderly patients and addresses surgical optimization, management of several cancer subtypes, surgical advances in minimally invasive surgery, and ethical considerations.

Is it safe to perform gastrectomy in gastric cancer patients aged 80 or older?: A meta-analysis and systematic review

BACKGROUND

Few studies have focused on octogenarian patients with gastric cancer (GC) who have undergone gastrectomy. This meta-analysis of published studies was performed to assess the safety of treating octogenarian GC patients with surgery.

METHODS

Databases, including PubMed, Embase, Web of Science, and Cochrane Library were searched until January 2019. The incidence of preoperative comorbidities, postoperative complications, and mortality was assessed using odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Further, the hazard ratios (HRs) with 95% CIs were applied for survival outcomes.

RESULTS

A total of 18,179 patients with GC in 21 studies were included. Our results demonstrated that octogenarian patients were associated with a higher burden of comorbidities (OR = 2.79; 95% CI: 2.37, 3.28; P = .00), high incidences of overall postoperative complications (OR = 1.48; 95% CI: 1.22, 1.81; P = .00), medical postoperative complications (OR = 2.58; 95% CI: 1.91, 3.49; P = .00), in-hospital mortality (OR = 3.24; 95% CI: 2.43, 4.31; P = .00) and poor overall survival (HR = 1.96; 95% CI: 1.65, 2.27; P = .00).

CONCLUSIONS

Considering the high burden of comorbidities, high incidences of postoperative complications and mortality, surgery for extremely elderly patients with GC requires deliberation. Individualized treatment is recommended for such patients.

Extremely High Mortality Rate after a Successful Gastrectomy for Cancer in Older Adults

PURPOSE

Poor physiological reserve for withstanding major cancer surgery in older adults is an important concern in the selection of patients for oncologic gastrectomy. The present study aimed to analyze mortality patterns among patients who underwent gastrectomy for cancer according to age groups. The primary outcomes of this study were early- and middle-term results: 30-day and 3-, 6-, 12-, and 36-month mortality rates.

MATERIALS AND METHODS

A retrospective review of 288 patients who underwent surgical resection for gastric cancer in two centers was carried out. Patients were stratified into four groups according to age: 29-50 years (group I, n=27), 51-65 years (group II, n=117), 66-75 years (group III, n=81), and 76-92 years (group IV, n=58). Statistical calculations focused on the differences in the survival rates between groups I and II as well as between groups II and IV.

RESULTS

The middle-aged patients (group II) had significantly better 3-year survival than either the youngest (group I) or the oldest patients (group IV). The 6-month mortality rates were 16.9% in group III and 29.3% in group IV. Two-thirds of the patients from groups III and IV who died between 2 and 6 months after surgery had an uneventful postoperative course.

CONCLUSIONS

Age is an important prognostic factor of middle-term survival after gastrectomy for cancer. Geriatric assessment and better patient selection for major surgery for cancer are required to improve the outcome of gastrectomy for cancer in patients aged over 75 years.

Predictive Value of Preoperative Sarcopenia in Patients with Gastric Cancer: a Meta-analysis and Systematic Review

PURPOSE

The impact of preoperative sarcopenia on postoperative complications and overall survival has been recently debated. Our meta-analysis aims to ascertain whether preoperative sarcopenia increases the risk of poor outcomes and to attempt to provide new ideas for the prognosis of outcomes for patients with gastric cancer.

METHODS

We searched for all relevant articles on PubMed, the EMBASE database, and Web of Science (up to September 1, 2017). Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

Thirteen studies involving 4262 patients who underwent gastrectomy for gastric cancer were analyzed (sarcopenia group = 1234; non-sarcopenia group = 3028). The results showed that preoperative sarcopenia significantly associated with poor pathological staging (high pT: OR = 1.86, 95% CI = 1.49-2.31; P < 0.01; pN+: OR = 1.61, 95% CI = 1.33-1.94; P < 0.01; high TNM category: OR = 1.84, 95% CI = 1.53-2.22; P < 0.01). Patients with preoperative sarcopenia had an increased risk of total postoperative complications (OR = 2.17, 95% CI = 1.53-3.08; P < 0.01), severe complications (OR = 1.65, 95% CI = 1.09-2.50; P = 0.02), and poorer OS (HR = 1.70, 95% CI = 1.45-1.99; P < 0.01). The results of subgroup analyses revealed that patients with preoperative sarcopenia over 65 years old and those from Asian populations had higher risks for total postoperative complications and severe complications.

CONCLUSION

This meta-analysis reveals that preoperative sarcopenia may be used as a new indicator of poor pathological staging, impaired overall survival, and increased postoperative complications. Notably, patients with gastric cancer who are over 65 years old and from Asia should be routinely screened for sarcopenia before surgery to adequately assess the risk of postoperative complications in clinical practice.

Surgical outcomes after gastrectomy in very elderly patients with gastric cancer

PURPOSE

Whether or not gastrectomy is feasible for very elderly gastric cancer patients is unclear. This study aimed to clarify the feasibility and safety of surgical treatment for patients in this age group.

METHOD

The study included 55 very elderly patients with resectable gastric cancer who underwent gastrectomy (≥ 85 years of age; very-E group). The surgical outcomes were compared with those of 611 elderly patients (75-84 years old; E group).

RESULTS

Female sex, a poor physical and performance status, and a low serum albumin level patients were more frequent in the very-E group than in the E group. Lymphadenectomy was less aggressive in the very-E group than in the E group (P < 0.001). The overall postoperative complication rate was not significantly different between the groups (46 vs 33%; P = 0.073). A multivariate analysis to predict the overall survival identified male sex (hazard ratio 1.75, 95% confidence interval 1.30-2.36), low body mass index (2.19, 1.52-3.16), poor performance status (2.14, 1.60-2.86), low serum albumin level (1.84, 1.37-2.48), and advanced tumor stage (1.71, 1.29-2.27) but not age (1.31, 0.84-2.03) as independent prognostic factors.

CONCLUSION

Chronological age alone is not a contraindicative factor for gastrectomy in very elderly patients.

Laparoscopic gastrectomy for elderly patients with gastric cancer: A systematic review with meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been widely applied in patients with gastric cancer (GC). However, the safety and application value of LG in elderly patients with GC was still unclear. In this study, we aimed to evaluate the feasibility and safety of LG for elderly patients with GC using the meta-analysis.

METHODS

Studies comparing elderly patients and nonelderly patients who underwent LG for GC were reviewed and collected from the PubMed, EBSCO, Cochrane Library, and EMBASE. Outcomes such as operative results, postoperative recovery, and morbidity were compared and analyzed. The Review Manager 5.3 was used to portray the weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

Eleven observational studies with a total of 3275 patients were included. Compared with nonelderly patients, elderly patients had shorter operation time (WMD -10.46; 95% CI -17.06 to -3.86; P = .002), less retrieved lymph nodes (WMD -2.34; 95% CI -3.77 to -0.92; P = .001), delayed time to first flatus (WMD 0.31; 95% CI 0.10-0.51; P = .003), longer postoperative hospital stays (WMD 1.06; 95% CI 0.07-2.05; P = .04), higher risk for overall postoperative complication (OR 1.34; 95% CI 1.08-1.67; P = .009), nonsurgical postoperative complication (OR 1.98; 95% CI 1.24-3.15; P = .004), and postoperative pulmonary complication (OR: 3.09; 95% CI 1.68-5.68; P < .001). There was no significance between nonelderly patients and elderly patients regarding the estimated blood loss, incidences of surgical postoperative complication, surgical site infection, and ileus (P > .05).

CONCLUSION

Outcomes of LG for elderly patients were comparable to those in nonelderly patients. Age alone should not preclude LG in elderly patients.

Is it beneficial to perform surgical resection in elderly patients more than 80 years old with advanced gastric cancer?

OBJECTIVES

With the aging population, the number of elderly patients diagnosed with gastric cancer is increasing. However, determining treatment strategies for elderly patients with gastric cancer is controversial. The aim of this study is to evaluate the usefulness of surgical treatment on elderly patients aged ≥80 years with advanced gastric cancer.

METHODS

A total of 147 elderly patients who were diagnosed with advanced gastric cancer from August 2001 to December 2015 were retrospectively analyzed. We compared the clinicopathological features and prognoses of 94 elderly patients (80-85 years) and 53 extreme-elderly patients (≥86 years) according to treatment modalities.

RESULTS

In the elderly group, the 3-year overall survival (OS) rates of the surgical resection group and supportive care group were 42.1% and 4.0%, respectively (p < .001). In the extreme-elderly group, the 3-year OS rates of the surgical resection group and supportive care group were 36.4% and 8.0%, respectively (p = .028). The post-operative mortality rate of the elderly group and extreme-elderly group was 5.6% and 9.1%, respectively. In the analysis of risk factors associated with survival, surgical resection was a significantly good prognostic factor in the elderly group (hazard ratio [HR] = 0.277; p = .003) compared with supportive care. In the extreme-elderly group, surgical resection was associated with good prognosis but did not reach statistical significance (HR = 0.491; p = .099).

CONCLUSIONS

These results suggest that elderly patients aged 80-85 years with advanced gastric cancer could expect a better prognosis with surgical resection. However, extreme-elderly patients aged ≥86 years should consider the risks and benefits of surgical treatment.

Sarcopenia: a new predictor of postoperative complications for elderly gastric cancer patients who underwent radical gastrectomy

BACKGROUND

A geriatric assessment is needed to identify high-risk elderly patients with gastric cancer. However, the current geriatric assessment has been considered to be either time-consuming or subjective. The present study aimed to investigate the predictive effect of sarcopenia on the postoperative complications for elderly patients who underwent radical gastrectomy.

MATERIALS AND METHODS

We conducted a prospective study of patients who underwent radical gastrectomy from August 2014 to December 2015. Computed tomography-assessed lumbar skeletal muscle, handgrip strength, and gait speed were measured to define sarcopenia.

RESULTS

Sarcopenia was present in 69 of 240 patients (28.8%) and was associated with lower body mass index, lower serum albumin, lower hemoglobin, and higher nutritional risk screening 2002 scores. Postoperative complications significantly increased in the sarcopenic patients (49.3% versus 24.6%, P < 0.001), compared with nonsarcopenic patients. The multivariate analysis demonstrated that sarcopenia (odds ratio: 2.959, 95% CI: 1.629-5.373, P < 0.001) and the Charlson comorbidity index ≥2 (odds ratio: 3.357, 95% CI: 1.144-9.848, P = 0.027) were independent risk factors for postoperative complications.

CONCLUSIONS

Sarcopenia, presented as a new geriatric assessment factor, was a strong and independent risk factor for postoperative complications of elderly patients with gastric cancer.

Gastrectomy with limited surgery for elderly patients with gastric cancer

BACKGROUND/OBJECTIVE

Elderly patients with gastric cancer can receive standard gastrectomy or gastrectomy with reduced nodal dissection, i.e., limited surgery, in order to prevent postoperative complications. This study evaluated the feasibility of gastrectomy with limited surgery for elderly patients with gastric cancer.

METHODS

A total of 267 elderly patients (≥70 years old) were divided into two groups according to the level of nodal dissection: patients who received nodal dissection according to guidelines were included in the standard surgery group (standard group), and those who received reduced nodal dissection were included in the limited surgery group (limited group). The surgical outcomes of the two groups were compared.

RESULTS

There were 170 patients in the standard group and 97 patients in the limited group. The limited group had significantly poorer nutrition status and a significantly higher proportion with comorbidities. Morbidity and mortality were similar in both groups. Multivariate analysis showed that the overall survival rates were significantly worse in patients with advanced age, male gender, low body mass index, low prognostic nutrition index, and higher tumor stage. The disease-specific survival rate was significantly lower in the limited group than in the standard group (p<0.001).

CONCLUSION

Gastrectomy according to the gastric treatment guidelines for elderly patients with gastric cancer is recommended. Elderly male patients with poor nutrition have poor prognosis; prognostic nutrition index <40. Limited surgery is a treatment option for such patients.

How could we identify the 'old' patient in gastric cancer surgery? A single centre cohort study

PURPOSE

To analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient.

METHODS

In a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable "age". All the significant variables were used to find predictors of complications with Clavien-Dindo>2.

RESULTS

Age>75 (AUC 0.61; 95% 0.55-0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54-0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00-1.01; p = 0.0001- AUC 0.62, 95% CI 0.56-0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04-0.93, p = 0.041 - AUC 0.74 95% CI 0.68-0.80; p = 0.003) and additional procedures (OR 7.05; 1.23-40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06-11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23-72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36-8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2.

CONCLUSIONS

Our work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events.

Sarcopenia predicts 1-year mortality in elderly patients undergoing curative gastrectomy for gastric cancer: a prospective study

PURPOSE

One-year mortality is vital for elderly oncologic patients undergoing surgery. Recent studies have demonstrated that sarcopenia can predict outcomes after major abdominal surgeries, but the association of sarcopenia and 1-year mortality has never been investigated in a prospective study.

METHODS

We conducted a prospective study of elderly patients (≥65 years) who underwent curative gastrectomy for gastric cancer from July 2014 to July 2015. Sarcopenia was determined by the measurements of muscle mass, handgrip strength, and gait speed. Univariate and multivariate analyses were used to identify the risk factors associated with 1-year mortality.

RESULTS

A total of 173 patients were included, in which 52 (30.1 %) patients were identified as having sarcopenia. Twenty-four (13.9 %) patients died within 1 year of surgery. Multivariate analysis showed that sarcopenia was an independent risk factor for 1-year mortality. Area under the receiver operating characteristic curve demonstrated an increased predictive power for 1-year mortality with the inclusion of sarcopenia, from 0.835 to 0.868. Solely low muscle mass was not predictive of 1-year mortality in the multivariate analysis.

CONCLUSIONS

Sarcopenia is predictive of 1-year mortality in elderly patients undergoing gastric cancer surgery. The measurement of muscle function is important for sarcopenia as a preoperative assessment tool.