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Mengardo V, Cormack OM, Weindelmayer J, Chaudry A, Bencivenga M, Giacopuzzi S, Allum WH, de Manzoni G. Multicenter Study of Presentation, Management, and Postoperative and Long-Term Outcomes of Septegenerians and Octogenerians Undergoing Gastrectomy for Gastric Cancer. Ann Surg Oncol 2018; 25:2374-2382. [PMID: 29868974 DOI: 10.1245/s10434-018-6543-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND The optimal treatment strategy for elderly patients with gastric cancer is still controversial. This study aimed to assess the impact of age on short- and long-term outcomes after treatment for primary gastric cancer. METHODS From January 2004 to December 2014, a total of 507 patients underwent gastrectomy for gastric adenocarcinoma at two high-volume upper gastrointestinal (GI) centers. The patients were classified into three groups as follows: group A (patients ≤ 69 years old, n = 266), group B (patients 70-79 years old, n = 166), and group C (patients ≥ 80 years old, n = 75). Clinicopathologic characteristics as well as, short- and long-term outcomes were compared between the groups. RESULTS The patients in groups B and C had more comorbidities, whereas the younger subjects (group A) had more advanced tumor stages. Less extensive surgery was performed in the groups B and C. Older patients (age ≥ 70 years) had more postoperative medical complications. Moreover, group C had a higher postoperative mortality rate (8.1%) than group A (1.8%) or group B (1.9%). In the multivariable analysis, age older than 80 years (group C) was a negative independent factor for overall survival (OS) (hazard ratio [HR], 2.36) compared with group A, whereas group B seemed to have a comparable risk (HR, 1.37). Notably, the three groups did not show significant differences in disease-related survival (DRS). CONCLUSION The data suggest that patients 70-79 years of age show a risk of postoperative death comparable with that of younger subjects. However, patients older than 80 years should be carefully selected for surgical treatment due to the increased risk of postoperative mortality.
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Affiliation(s)
- Valentina Mengardo
- General and Upper GI Surgery Division, University of Verona, Verona, Italy.
| | - Orla Mc Cormack
- Department of Upper Gastrointestinal Surgery, Royal Marsden Hospital, London, UK
| | | | - Asif Chaudry
- Department of Upper Gastrointestinal Surgery, Royal Marsden Hospital, London, UK
| | - Maria Bencivenga
- General and Upper GI Surgery Division, University of Verona, Verona, Italy
| | - Simone Giacopuzzi
- General and Upper GI Surgery Division, University of Verona, Verona, Italy
| | - William H Allum
- Department of Upper Gastrointestinal Surgery, Royal Marsden Hospital, London, UK
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Pisanu A, Montisci A, Piu S, Uccheddu A. Curative Surgery for Gastric Cancer in the Elderly: Treatment Decisions, Surgical Morbidity, Mortality, Prognosis and Quality of Life. TUMORI JOURNAL 2018; 93:478-84. [DOI: 10.1177/030089160709300512] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background Surgical risk is deemed to be higher in the aged population because there are often comorbidities that may affect the postoperative result. This consideration is important for the treatment decision-making for gastric cancer in the elderly. The aim of this study was to identify factors influencing mortality, morbidity, survival and quality of life after curative surgery for gastric cancer in patients aged 75 years and older, and to plan their appropriate management. Methods and Study Design From January 1993 to December 2004, 135 patients underwent surgery at our department because of gastric cancer. Ninety-four of these patients (69.6%) underwent potentially curative gastrectomy. A cross-sectional study of 23 patients aged 75 years and older and 71 younger patients who underwent curative gastrectomy was carried out: patient characteristics, tumor characteristics, management, morbidity, mortality, survival, and quality of life were evaluated. Results Elderly patients had significantly more comorbidities and a poorer nutritional status than younger patients. The surgical procedures were similar in both groups and the overall morbidity rate was 27.9% and the overall mortality rate 8.5%. Medical mortality was significantly higher in elderly patients, and the presence of comorbidities was the only independent factor affecting mortality. The 5-year survival rate was 56.2% in the older group versus 62.1% in the younger group and tumor stage was the only prognostic factor influencing survival. Quality of life after surgery was similar in both groups. The significantly better postoperative functional outcome after subtotal gastrectomy suggested a better compliance of elderly patients with subtotal than total gastrectomy. Conclusions In the elderly, surgical strategies must be modulated on the basis of comorbidities, tumor stage and future quality of life. Since elderly patients have no worse prognosis than younger patients, age is not a contraindication to curative resection for gastric cancer. Subtotal gastrectomy should be the procedure of choice mainly in elderly patients as it offers better quality of life.
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Affiliation(s)
- Adolfo Pisanu
- Department of Surgery, Clinica Chirurgica of the University of Cagliari, Cagliari, Italy
| | - Alessandro Montisci
- Department of Surgery, Clinica Chirurgica of the University of Cagliari, Cagliari, Italy
| | - Sara Piu
- Department of Surgery, Clinica Chirurgica of the University of Cagliari, Cagliari, Italy
| | - Alessandro Uccheddu
- Department of Surgery, Clinica Chirurgica of the University of Cagliari, Cagliari, Italy
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Ruspi L, Galli F, Pappalardo V, Inversini D, Martignoni F, Boni L, Dionigi G, Rausei S. Lymphadenectomy in elderly/high risk patients: should it be different? Transl Gastroenterol Hepatol 2017; 2:5. [PMID: 28217755 DOI: 10.21037/tgh.2016.12.07] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/27/2016] [Indexed: 12/26/2022] Open
Abstract
The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.
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Affiliation(s)
- Laura Ruspi
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Federica Galli
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Vincenzo Pappalardo
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Davide Inversini
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Francesco Martignoni
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Luigi Boni
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Gianlorenzo Dionigi
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
| | - Stefano Rausei
- Department of General Surgery, University of Insubria, 21100 Varese, Italy; Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
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Abstract
BACKGROUND Surgery in gastric cancer (GC) aims to achieve resection of the primary tumor and its lymphatic drain, with a minimal adverse effect on morbidity and mortality, and the best possible quality of life. METHODS From June 1993 to May 2008, 113 patients with a preoperative diagnosis of the GC were considered for laparoscopic gastrectomy at our institution. There was a predominance of males and mean age was 60 years. After peritoneal cavity inspection, laparoscopic ultrasound was used to determine the presence of deep liver metastasis. Total gastrectomy and Roux-en-Y reconstruction were performed in upper and middle-third tumors, and subtotal gastrectomy, either with Billroth II or Roux-en-Y reconstruction, in tumors affecting the lower third of the stomach. D2 lymphadenectomy was performed in both cases. RESULTS There were 21 cases (18.5%) with distant metastases and/or an unresectable tumor due to the invasion of adjacent organs. In these patients the procedure was limited to laparoscopic biopsy in 16 cases and laparoscopic gastrojejunostomy in 5 cases. Laparoscopic gastrectomy was performed in 92 patients with a mean surgical time of 162 minutes and a mortality rate of 5.4%. Conversion was necessary in 7 cases (7.6%). CONCLUSIONS The benefits and safety of laparoscopic gastrectomy are evident, with similar outcomes to conventional surgery and all the advantages of minimally invasive access. The learning curve is long. Laparoscopic gastrectomy is a safe and effective option for the treatment of GC, avoiding nontherapeutic laparotomy in patients with advanced disease. Comparative prospective studies evaluating the long-term survival of these patients are still necessary.
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Choi IS, Oh DY, Kim BS, Lee KW, Kim JH, Lee JS. Oxaliplatin, 5-FU, folinic acid as first-line palliative chemotherapy in elderly patients with metastatic or recurrent gastric cancer. Cancer Res Treat 2007; 39:99-103. [PMID: 19746224 DOI: 10.4143/crt.2007.39.3.99] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 09/01/2007] [Indexed: 01/20/2023] Open
Abstract
PURPOSE We investigated the efficacy and safety of a combination of oxaliplatin, 5-fluorouracil (5-FU), and folinic acid (FA) as first-line palliative chemotherapy for elderly patients with metastatic or recurrent gastric cancer. MATERIALS AND METHODS The study patients were chemotherapy-naïve patients (> 65 years old) with histologically confirmed, metastatic or recurrent gastric cancer. Chemotherapy consisted of oxaliplatin 100 mg/m(2) and FA 100 mg/m(2) (2-hour infusion), and then 5-FU 2400 mg/m(2) (46-hour continuous infusion) every 2 weeks. RESULTS A total of 37 patients were studied between April 2004 and October 2006. Of the 34 evaluable patients, none achieved a complete response (CR) and 14 achieved a partial response (PR), resulting in an overall response rate of 41.2%. The median time to progression (TTP) was 5.7 months (95% CI: 4.2~6.3 months) and the median overall survival (OS) was 9.8 months (95% CI: 4.4~12.0 months). The main hematologic toxicities were anemia and neutropenia, which were observed in 56.7% and 32.4% of the patients, respectively. Grade 3/4 neutropenia was observed in 8.1% of the patients. None of the patients experienced febrile neutropenia. Peripheral neuropathy occurred in 35.1% of the patients and all were grade 1/2. CONCLUSION This oxaliplatin/5-FU/FA regimen showed good efficacy and an acceptable toxicity profile in elderly patients with metastatic or recurrent gastric cancer.
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Affiliation(s)
- In Sil Choi
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kulig J, Popiela T, Kolodziejczyk P, Sierzega M, Jedrys J, Szczepanik AM. Clinicopathological profile and long-term outcome in young adults with gastric cancer: multicenter evaluation of 214 patients. Langenbecks Arch Surg 2007; 393:37-43. [PMID: 17618451 DOI: 10.1007/s00423-007-0208-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 06/14/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Gastric cancer (GC) is usually diagnosed in the sixth and seventh decade of life, although it may also be found in younger patients. The aim of this study was to analyse the potential differences in demographic and clinicopathological factors between the younger (40 years of age and less) and older (above 40 years) population of GC. MATERIALS AND METHODS An electronic database covering all gastric cancer patients treated between 1977 and 1998 at eight university surgical centres was reviewed. RESULTS Of 3,431 patients treated, 214 (6.2%) were 40 years of age or younger. No differences in tumour staging or location could be identified, but the diffuse type lesions were more common in the younger patients (52.6 vs 29.8%). No differences were found in morbidity and mortality rates, except a higher incidence of cardiopulmonary complications in older patients undergoing stomach resection (6.6 vs 12.3%). Median survival of patients after gastrectomy was 24.7 months (95% confidence interval [CI] 22.7-26.6) and was insignificantly longer in younger (30.8 months, 95%CI 21.0-40.5) than older (24.1 months, 95%CI 22.1-26.1) patients (P = 0.056). Median survival for unresectable cases was 5.4 months (95%CI 5.1-5.7) and was comparable in the younger (median 5.5 months, 95%CI 5.2-5.8) and older (median 4.4 months, 95%CI 3.7-5.1) groups. CONCLUSION GC in young adults demonstrates only minor deviations from the general population with a similar long-term outcome.
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Affiliation(s)
- Jan Kulig
- 1st Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501 Krakow, Poland.
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Kim DY, Joo JK, Park YK, Ryu SY, Kim YJ, Kim SK, Lee JH. Is palliative resection necessary for gastric carcinoma patients? Langenbecks Arch Surg 2007; 393:31-5. [PMID: 17593384 DOI: 10.1007/s00423-007-0206-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Accepted: 06/01/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS The benefit of palliative resection for gastric carcinoma patients remains controversial. We thus evaluated the survival benefit of palliative resection in advanced gastric carcinoma patients. MATERIALS AND METHODS We reviewed the hospital records of 466 gastric carcinoma patients who had palliative resection and compared the clinicopathologic findings to those of patients who underwent a bypass or exploration from 1986 to 2000. RESULTS Cox's proportional hazard regression model revealed only one independent statistically significant prognostic parameter, the presence of peritoneal dissemination (risk ratio, 0.739; 95% confidence interval, 0.564-0.967; P < 0.05). The 5-year survival rate of patients who had palliative resection was higher than that of patients who did not (7.03 vs 0%, P < 0.001). When the 5-year survival rates of patients with peritoneal dissemination were examined, the rate was higher for those who underwent resection (4.43 vs 0%, P < 0.001). CONCLUSION The results highlight the improved survivorship of gastric carcinoma patients with palliative resection compared to those who did not undergo the procedure. Although curative resection is not possible in this group of patients, we recommend performing resection aimed at palliation.
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Affiliation(s)
- Dong Yi Kim
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School, 8, Hakdong, Dongku, Gwangju 501-757, South Korea.
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8
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Santini D, Graziano F, Catalano V, Di Seri M, Testa E, Baldelli AM, Giordani P, La Cesa A, Spalletta B, Vincenzi B, Russo A, Caraglia M, Virzi V, Cascinu S, Tonini G. Weekly oxaliplatin, 5-fluorouracil and folinic acid (OXALF) as first-line chemotherapy for elderly patients with advanced gastric cancer: results of a phase II trial. BMC Cancer 2006; 6:125. [PMID: 16686939 PMCID: PMC1475875 DOI: 10.1186/1471-2407-6-125] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 05/10/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elderly patients have been often excluded from or underrepresented in the study populations of combination chemotherapy trials. The primary end point of this study was to determine the response rate and the toxicity of the weekly oxaliplatin, 5-fluorouracil and folinic acid (OXALF) regimen in elderly patients with advanced gastric cancer. The secondary objective was to measure the time to disease progression and the survival time. METHODS Chemotherapy-naive patients with advanced gastric cancer aged 70 or older were considered eligible for study entry. Patients received weekly oxaliplatin 40 mg/m2, fluorouracil 500 mg/m2 and folinic acid 250 mg/m2. All drugs were given intravenously on a day-1 schedule. RESULTS A total of 42 elderly patients were enrolled. Median age was 73 years and all patients had metastatic disease. The response rate according to RECIST criteria was 45.2% (95% CIs: 30%-56%) with two complete responses, 17 partial responses, 13 stable diseases and 10 progressions, for an overall tumor rate control of 76.2% (32 patients). Toxicity was generally mild and only three patients discontinued treatment because of treatment related adverse events. The most common treatment-related grade 3/4 adverse events were fatigue (7.1%), diarrhoea (4.8%), mucositis (2.4%), neurotoxicity (2.4%) and neutropenia (4.8%). The median response duration was 5.3 months (95% CIs: 2.13 - 7.34), the median time to disease progression was 5.0 months (95% CIs: 3.75 - 6.25) and the median survival time was 9.0 months (95% CIs: 6.18 - 11.82). CONCLUSION OXALF represents an active and well-tolerated treatment modality for elderly patients with locally advanced and metastatic gastric cancer.
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Affiliation(s)
- D Santini
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - F Graziano
- Medical Oncology, Civic Hospital, Urbino, Italy
| | - V Catalano
- Medical Oncology, Civic Hospital, Pesaro, Italy
| | - M Di Seri
- Medical Oncology, University La Sapienza, Rome, Italy
| | - E Testa
- Medical Oncology, Civic Hospital, Urbino, Italy
| | - AM Baldelli
- Medical Oncology, Civic Hospital, Pesaro, Italy
| | - P Giordani
- Medical Oncology, Civic Hospital, Pesaro, Italy
| | - A La Cesa
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - B Spalletta
- Medical Oncology, University La Sapienza, Rome, Italy
| | - B Vincenzi
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - A Russo
- Medical Oncology, University of Palermo, Italy
| | - M Caraglia
- National Cancer Institute Fondazione "G. Pascale", Experimental Oncology, Department, Experimental Pharmacology Unit, Naples, Italy
| | - V Virzi
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - S Cascinu
- Division of Medical Oncology, University of Ancona, Ancona, Italy
| | - G Tonini
- Medical Oncology, University Campus Bio-Medico, Rome, Italy
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Peeters KCMJ, Hundahl SA, Kranenbarg EK, Hartgrink H, van de Velde CJH. Low Maruyama index surgery for gastric cancer: blinded reanalysis of the Dutch D1-D2 trial. World J Surg 2006; 29:1576-84. [PMID: 16317484 DOI: 10.1007/s00268-005-7907-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A quantitative estimate of residual nodal disease after gastric cancer surgery, the Maruyama index of unresected disease (MI), proved to be a strong independent predictor of survival in a large U.S. adjuvant chemoradiation study in which surgical undertreatment was frequent. Data from the Dutch D1-D2 Lymphadenectomy Trial permit an opportunity to assess the prognostic value of this variable in a cohort with lower-stage disease treated with minimum D-1 lymphadenectomy and no adjuvant chemoradiation. Blinded to survival, and excluding those cases with missing information, the MI was calculated for 648 of the original 711 patients treated with curative intent. Survival was assessed by log-rank and multivariate Cox regression analysis. All patients have been followed for a minimum of 11 years. Overall Dutch trial findings were not affected by the absence of 63 cases with incomplete data. As expected, the median MI was 26, much lower than in the previous U.S. study. In contrast to the D level, MI < 5 proved to be a strong predictor of survival by both univariate and multivariate analysis. The MI was an independent predictor of both overall survival [P = 0.016; hazard ratio (HR) = 1.45; 95% confidence interval (CI) 1.07-1.95] and relapse risk (P = 0.010; HR = 1.72; 95% CI 1.14-2.60). A strong dose-response reaction with respect to the MI and survival was also observed. We conclude that in this trial low-MI surgery is associated with enhanced survival, whereas outside of certain subgroups routine D2 lymphadenectomy is not. This observation suggests that surgeons might have more of an impact on patient survival by achieving a low-MI operation than a particular D level. A compelling dose-response effect reveals that the MI is a quantitative yardstick for assessing the adequacy of lymphadenectomy in gastric cancer.
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Affiliation(s)
- K C M J Peeters
- Department of Surgery, K6-R, Leiden University Medical Center, PO Box 9600, RC Leiden, 2300, The Netherlands
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10
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Dowdall JF, McAnena OJ. Linear stapling of the short gastric vessels reduces blood loss and splenectomy at oesophageal and gastric surgery. Surg Endosc 2006; 20:770-2. [PMID: 16424989 DOI: 10.1007/s00464-004-9115-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Accepted: 10/08/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Increased operative blood loss, blood transfusion and nontherapeutic splenectomy negatively influence postoperative morbidity and mortality following esophageal or gastric resection. A critical point at which blood loss and iatrogenic splenic injury occurs is at the time of division of the short gastric vessels. We examined the efficacy of using a laparoscopic linear cutting stapler (developed for minimal access surgery) to divide with the short gastric vessels at open surgery. METHODS Fifty-six patients were included. In 28 consecutive patients the linear stapler was used when dividing the short gastric vessels. These were compared to 28 matched controls (short gastric vessels were divided between hemostats and ligated). In the two patient groups, patient age, body mass index, and preoperative hemoglobin levels were similar. RESULTS Operation time, splenectomy rates, blood transfusion, and mean transfusion volume were all significantly reduced in the group where the stapler was used. CONCLUSION Use of a linear cutting stapler reduced operation time, blood product use, and incidental splenectomy in patients undergoing radical open esophageal and gastric surgery.
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Affiliation(s)
- J F Dowdall
- Department of Surgery, University College Hospital, New Castle, Galway, Ireland
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Kycler W, Teresiak M, Łoziński C. Prognostic factors for patients with gastric cancer after surgical resection. Rep Pract Oncol Radiother 2006. [DOI: 10.1016/s1507-1367(06)71069-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Samarasam I, Chandran BS, Sitaram V, Perakath B, Nair A, Mathew G. Palliative gastrectomy in advanced gastric cancer: is it worthwhile? ANZ J Surg 2006; 76:60-3. [PMID: 16483298 DOI: 10.1111/j.1445-2197.2006.03649.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastric cancer remains one of the leading causes of cancer-related deaths. Many patients present late, and therefore, resections are often palliative in nature. The aim of this study was to assess the feasibility of resectional operation and the survival advantage of surgical resection in advanced gastric cancer. The effectiveness of palliation and the quality of life following operation for gastric cancer were assessed. METHODS One hundred and fifty-one patients who underwent operation for gastric cancer at a tertiary centre in South India during a 5-year period between 1999 and 2003, were included in this study. Four sites of tumour spread were used as indicators of incurability in these patients. These were unresectable primary tumour or macroscopic residual primary tumour (T+), unresectable lymph nodal metastasis (L+), unresectable liver metastasis (H+) and peritoneal metastasis (P+). The resectability rate and survival were assessed in relation to these four factors. RESULTS The resectability rate decreased as the number of sites of tumour spread increased. The overall survival was significantly better in the subgroup of patients who had a resectional operation (total gastrectomy or subtotal gastrectomy), as opposed to the subgroup who had non-resectional operation (exploratory laparotomy or laparotomy with gastrojejunostomy) (P = 0.0003). This survival advantage of resectional operation disappeared when more than two sites of tumour spread were present. The quality of life was significantly better when a resection operation was carried out. CONCLUSION In advanced gastric cancer, palliative resection has a survival advantage if the tumour spread is restricted to two or less sites. Patients who undergo resectional operation have better palliation of symptoms and their postoperative quality of life is significantly better.
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Affiliation(s)
- Inian Samarasam
- Department of General Surgery, Christian Medical College and Hospital, Vellore 632-004, Tamil Nadu, India.
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13
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Hartgrink HH, van de Velde CJH. Status of extended lymph node dissection: Locoregional control is the only way to survive gastric cancer. J Surg Oncol 2005; 90:153-65. [PMID: 15895448 DOI: 10.1002/jso.20222] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There are many factors that are of influence on gastric cancer treatment. The only way to survive is complete locoregional control. More extended dissections should lead to better outcome, but increased morbidity and mortality probably offset its long-term effect in survival in randomised studies. In this article the factors of influence on outcome of gastric cancer treatment such as the extent of lymph node dissection, splenectomy, pancreatectomy, age, volume and additional treatments are discussed. A literature review of these factors in relation to the latest results of the Dutch Gastric Cancer Trials are presented. If morbidity and mortality can be reduced there might be an advantage of extended lymph node dissection. Splenectomy and pancreatectomy should be performed only in case of direct in growth from the tumour into these organs. Centralisation of gastric cancer treatment should be achieved in order to improve results and to facilitate research. By refining selection criteria in the treatment of gastric cancer further improvements are to be expected.
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Affiliation(s)
- Henk H Hartgrink
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
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14
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Coniglio A, Tiberio GAM, Busti M, Gaverini G, Baiocchi L, Piardi T, Ronconi M, Giulini SM. Surgical treatment for gastric carcinoma in the elderly. J Surg Oncol 2004; 88:201-5. [PMID: 15565628 DOI: 10.1002/jso.20153] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The incidence of gastric cancer is increasing in the elderly. The aim of this study is to evaluate the impact of advanced age (> or =80 years) on morbidity, mortality and late outcome after curative surgery for gastric cancer. METHODS The cases of 30 octogenarians (Group A) with gastric cancer who underwent surgical treatment in our Institution from 1990 to 2003 were reviewed and compared to a simultaneous group of 228 younger patients (Group B). RESULTS The rate of resective and curative procedures was not different in the two groups, although the American Society of Anaesthesiologists (ASA) risk was significantly higher in the elderly (P < 0.001) and the lymphatic dissection was less extended in group A. In the two groups, the curability was directly correlated to the cancer stage, but not affected by the ASA risk. The postoperative morbidity and mortality rates were similar in the two groups and were not related to the ASA risk. Considering the mortality for gastric cancer alone, the two groups showed a similar survival rate, only correlated to the cancer stage. CONCLUSIONS In the elderly, an oncologically correct surgical procedure can safely be prosecuted with satisfactory immediate and late results.
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Affiliation(s)
- Arianna Coniglio
- Surgical Clinic, Department of Medical and Surgical Sciences, Brescia University, Brescia, Italy
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15
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Affiliation(s)
- James M McLoughlin
- Department of Surgery, Baylor University Medical Center, Dallas, Texas 75246, USA
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Hartgrink HH, van de Velde CJH, Putter H, Bonenkamp JJ, Klein Kranenbarg E, Songun I, Welvaart K, van Krieken JHJM, Meijer S, Plukker JTM, van Elk PJ, Obertop H, Gouma DJ, van Lanschot JJB, Taat CW, de Graaf PW, von Meyenfeldt MF, Tilanus H, Sasako M. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004; 22:2069-77. [PMID: 15082726 DOI: 10.1200/jco.2004.08.026] [Citation(s) in RCA: 641] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years. CONCLUSION Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.
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Affiliation(s)
- H H Hartgrink
- Department of Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Abstract
The past decade has seen many advances in knowledge about gastric cancer. Notably, tumour biology and lymphatic spread are now better understood, and treatment by surgical and medical oncologists has become more standardised. Since refrigerators have replaced other methods of food conservation, Helicobacter pylori has become a factor in the cause of gastric cancer. Cancers that arise at the oesophagogastric junction might be further examples of wealth-associated disease. To tailor treatment better, the western hemisphere needs to borrow from the East by establishing screening programmes for early diagnosis, through careful surgical resection, and through detailed analysis of tumour spread. In Europe and the USA, most patients reach treatment with cancers already at an advanced stage. For these patients, three important randomised trials are underway that evaluate combined therapy. Cytostatic drugs, especially angiogenesis inhibitors have proved disappointing; however, basic research efforts to detect familial gastric cancers and to assess minimally residual disease look more hopeful.
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Hartgrink HH, Putter H, Klein Kranenbarg E, Bonenkamp JJ, van de Velde CJH. Value of palliative resection in gastric cancer. Br J Surg 2002; 89:1438-43. [PMID: 12390389 DOI: 10.1046/j.1365-2168.2002.02220.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Western patients with gastric cancer often present with incurable disease. The role of palliative surgical resection is still debatable. Non-curatively treated patients from the Dutch Gastric Cancer Trial were studied to define more accurately which patients might benefit from palliative resection. METHODS In the Dutch Gastric Cancer Trial 285 (26 per cent) of the randomized patients were found to have incurable tumours at laparotomy. Four signs of incurability were noted: irresectable tumour (T+), hepatic metastasis (H+), peritoneal metastasis (P+) and distant lymph node metastasis (N4+). Patients had either an explorative laparotomy, a gastroenterostomy, or a resection (partial or total). In the analysis, particular attention was paid to the prognostic factors of age, number of metastatic features, and a combination of these. RESULTS Overall survival time was greater if a resection was performed (8.1 versus 5.4 months; P < 0.001). For patients aged over 70 years there was still a survival advantage of about 3 months if resection was carried out. Morbidity and perioperative mortality rates in this older age group were, however, high (50 and 20 per cent respectively). For patients with one metastatic site a resection was of significant benefit (survival 10.5 versus 6.7 months; P = 0.034). For patients with two or more metastatic sites resection had no significant survival advantage (5.7 versus 4.6 months; P = 0.084). Combination of these factors indicates that patients aged less than 70 years with one metastatic site will benefit significantly from a palliative resection, in contrast to other combinations of factors. CONCLUSION Age as well as the number of metastatic sites should be taken into account when a palliative resection is considered. Palliative resection may be beneficial for patients under 70 years of age if the tumour load is restricted to one metastatic site.
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Affiliation(s)
- H H Hartgrink
- Department of Surgery, Leiden University Medical Centre, The Netherlands.
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Hartgrink HH, Bonenkamp HJ, van de Velde CJ. Influence of Surgery on Outcomes in Gastric Cancer. Surg Oncol Clin N Am 2000. [DOI: 10.1016/s1055-3207(18)30171-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact.
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Affiliation(s)
- A J Bremers
- Department of Oncologic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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